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Abdominal Assessment Case Study

Subjective:
•CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
•HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 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 afterwards.
•PMH: HTN, Diabetes, hx of GI bleed 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; occasional etoh, married, 3 children (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 wall symmetrical
•Skin: Intact without lesions, no urticaria
•Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
•Diagnostics: None
Assessment:
•Left lower quadrant pain
•Gastroenteritis
RESOURCES:
1) Abdominal pain
https://class.content.laureate.net/192d9f054fd0dbf89ddcd15dc023d33f.pdf
2) Constipation
https://class.content.laureate.net/7abbf888c2129a30d6932af5af7ca474.pdf
3) Diarrhea
https://class.content.laureate.net/e3ae95651bd43bda6862bf887581b967.pdf
4) Rectal pain, itching, and bleeding
https://class.content.laureate.net/b8cde2ca07a1334b6d2b1f0aa8bcd3e1.pdf

Sample Solution

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