Assessing the Abdomen

ABDOMINAL ASSESSMENT Subjective: CC: “My abdomen hurts, I accept diarrhea and annihilation seems to help.” HPI: JR, 47 yo WM, complains of accepting ambiguous belly affliction that started 3 canicule ago. He has not taken any medications because he did not apperceive what to take. He states the affliction is a 5/10 today but has been as abundant as 9/10 back it aboriginal started. He has been able to eat, with some abhorrence afterwards. PMH: HTN, Diabetes, hx of GI drain 4 years ago Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs Allergies: NKDA FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD Social: Denies tobacco use; casual etoh, married, 3 accouchement (1 girl, 2 boys) Objective: VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs Heart: RRR, no murmurs Lungs: CTA, chest bank symmetrical Skin: Intact after lesions, no urticaria Abd: soft, hyperactive bowel sounds, pos affliction in the LLQ Diagnostics: None Assessment: Left lower division pain Gastroenteritis Analyze the abstract allocation of the note. List added advice that should be included in the documentation. Analyze the cold allocation of the note. List added advice that should be included in the documentation. Is the appraisal accurate by the abstract and cold information? Why or why not? What analytic tests would be adapted for this case, and how would the after-effects be acclimated to accomplish a diagnosis? Would you reject/accept the accepted diagnosis? Why or why not? Identify three accessible altitude that may be advised as a cogwheel analysis for this patient. Explain your acumen application at atomic three altered references from accepted evidence-based literature. APA 4 to 5 References aural 5 years

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