NURS 6512
Abdominal and Gastrointestinal Case Study
Acute Adult and Gerontology Advanced Nurse Practitioner,
Walden University
NURS 6512: Advanced Health Assessment and Diagnostic
Abstract
This paper will analysis a episodic soap noted based off of given case study. This analysis will
evaluate the information collected and determine if any information should be added. This
analysis will also determine is the current diagnosis would be accepted or rejected as well as any
differential diagnosis that could be considered.
Abdominal and Gastrointestinal
Gathering subjective and objective data is a crucial element in helping healthcare
providers come up with a accurate diagnosis and plan of care. This analysis will exam the
information gathered in this case study and list additional information that should be included in
the documentation. It is imperative to do an accurate investigation to accumulate the clinical data
and bolster the right findings with current evidenced-based practice. Using the information
gathered along with a physical examination and diagnostic testing will help determine a accurate
diagnosis and plan of care. This analysis will offer additional testing and differential diagnosis
based off information gathered.
Subjective Data
CC: “My stomach hurts, I have diarrhea and nothing seems to help”
HPI: JR, 47 year old white-male, complains of having generalized abdominal pain that
started 3 days ago. He has not taken any medication because he did not know what to
take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started.
He has been able to eat with some nausea afterwards.
, PMH: HTN, DM, Hx of GI bleed 4 years ago.
Medications: Lisinopril 10mg, Amlodipine 5mg, Metformin 1000mg, Lantus 10 units
QHS.
Allergies: NKDA
FH: No Hx of colon cancer, father hx of DMT2, HTN, mother hx of HTN, GERD
Hyperlipidemia
Social Hx: Denies tobacco use, occasional ETOH, married with 3 children (1 girl, 2
Boys).
The subjective data collected from this patient is not as thorough as it could be. Thorough
subjective data is vital to determine the right diagnosis (Raleigh and Allen, 2017). Having a
thorough patient and family history is required with a specific end goal to survey and pick the
right diagnosis (Epocrates patient resources, 2018). During this investigation stage the healthcare
provider must gathered all pertinent information to help formulate a diagnosis and plan of care.
The patient stated this began three days ago, determining what the patient was doing prior to this
incident, did they eat something, was it different from the norm, did they drink something
different? How did they feel prior to the start of the diarrhea? Have you noticed any bleeding?
What color is your stool? Was there any nausea and vomiting when this occurred? Have the
patient taken anything to help relieve the pain? What have you done to make the pain better?
Incorporating more data to describe the pain, for example, the PQRST (provocation/palliation,
quality, location, radiation, and timing) technique for describing the pain (Young, 2017). The
cause of previous GI bleed, treatment, and care provided for the GI bleed. Also, a more in depth
understanding of the clients family history is important. Other than colon cancer, DM, HTN and
GI bleed do the patient have any other health issues or concerns. Have the patient had surgery?
Have the patient ever been admitted to the hospital? Are your parents still alive? What about the
patients maternal and paternal grandparents and their health history? Do the patients children
have a health history? We know the patient have no allergies to drugs but what about food or
Abdominal and Gastrointestinal Case Study
Acute Adult and Gerontology Advanced Nurse Practitioner,
Walden University
NURS 6512: Advanced Health Assessment and Diagnostic
Abstract
This paper will analysis a episodic soap noted based off of given case study. This analysis will
evaluate the information collected and determine if any information should be added. This
analysis will also determine is the current diagnosis would be accepted or rejected as well as any
differential diagnosis that could be considered.
Abdominal and Gastrointestinal
Gathering subjective and objective data is a crucial element in helping healthcare
providers come up with a accurate diagnosis and plan of care. This analysis will exam the
information gathered in this case study and list additional information that should be included in
the documentation. It is imperative to do an accurate investigation to accumulate the clinical data
and bolster the right findings with current evidenced-based practice. Using the information
gathered along with a physical examination and diagnostic testing will help determine a accurate
diagnosis and plan of care. This analysis will offer additional testing and differential diagnosis
based off information gathered.
Subjective Data
CC: “My stomach hurts, I have diarrhea and nothing seems to help”
HPI: JR, 47 year old white-male, complains of having generalized abdominal pain that
started 3 days ago. He has not taken any medication because he did not know what to
take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started.
He has been able to eat with some nausea afterwards.
, PMH: HTN, DM, Hx of GI bleed 4 years ago.
Medications: Lisinopril 10mg, Amlodipine 5mg, Metformin 1000mg, Lantus 10 units
QHS.
Allergies: NKDA
FH: No Hx of colon cancer, father hx of DMT2, HTN, mother hx of HTN, GERD
Hyperlipidemia
Social Hx: Denies tobacco use, occasional ETOH, married with 3 children (1 girl, 2
Boys).
The subjective data collected from this patient is not as thorough as it could be. Thorough
subjective data is vital to determine the right diagnosis (Raleigh and Allen, 2017). Having a
thorough patient and family history is required with a specific end goal to survey and pick the
right diagnosis (Epocrates patient resources, 2018). During this investigation stage the healthcare
provider must gathered all pertinent information to help formulate a diagnosis and plan of care.
The patient stated this began three days ago, determining what the patient was doing prior to this
incident, did they eat something, was it different from the norm, did they drink something
different? How did they feel prior to the start of the diarrhea? Have you noticed any bleeding?
What color is your stool? Was there any nausea and vomiting when this occurred? Have the
patient taken anything to help relieve the pain? What have you done to make the pain better?
Incorporating more data to describe the pain, for example, the PQRST (provocation/palliation,
quality, location, radiation, and timing) technique for describing the pain (Young, 2017). The
cause of previous GI bleed, treatment, and care provided for the GI bleed. Also, a more in depth
understanding of the clients family history is important. Other than colon cancer, DM, HTN and
GI bleed do the patient have any other health issues or concerns. Have the patient had surgery?
Have the patient ever been admitted to the hospital? Are your parents still alive? What about the
patients maternal and paternal grandparents and their health history? Do the patients children
have a health history? We know the patient have no allergies to drugs but what about food or
