A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.
Because of a hi...
Advanced Health Assessment & Diagnostic Reasoning (Walden
University )
, lOMoARcPSD|3013804
Running head: ASSIGNMENT 1: LAB ASSIGNMENT: ASSESSING THE 1
Assignment 1: Lab Assignment: Assessing the Abdomen
Walden University
Advanced Health Assessment
NURS - 6512
, lOMoARcPSD|3013804
ASSIGNMENT 1: LAB ASSIGNMENT: ASSESSING THE 2
Assignment 1: Lab Assignment: Assessing the Abdomen
The objectives of this assignment are to analyze an episodic note case study for the
assessment of the abdomen and gastrointestinal system provided by the professor. The episodic
case note provides subjective and objective information, along with an assessment containing
two diagnoses of left lower quadrant pain and gastroenteritis. This paper ends with a plan
which is not required for the assignments in this course.
Abdominal Assessment Case Study Episodic Note Transcript
Subjective: Chief Compliant/Concern: "My stomach hurts, I have diarrhea & nothing
seems to help." • History of Present Illness: JR, a 47-year-old white male complains of having
generalized abdominal pain that started three days ago. He has not taken any medications
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 afterward. • Patient
Medical History: HTN, Diabetes, history of GI bleed four years ago • Medications: Lisinopril
10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units q hs • Allergies: NKDA • Family
History: No history of colon cancer, Patient's father history DMT2, HTN and Patient's Mother
history HTN, Hyperlipidemia, GERD. Social History: Denies tobacco use; occasional alcohol
use, married, three children (one girl, two boys)
Objective: Vital Signs: Temp 99.8; BP 160/86, RR 16, P 92; HT 5'10; WT 248 lbs. Heart
RRR, no murmurs. Lungs: CTA, chest wall, symmetrical. Skin: Intact without lesions, no
urticaria. Abdomen: Soft, hyperactive bowel sounds, really intense pain in the LLQ.
The diagnostic assessments are left lower quadrant pain and gastroenteritis. The plan
section is not required for the assignments in this course (NURS 6512) but will be required for
future courses.
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