Abdominal Assessment

  1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
  3. Is the assessment supported by the subjective and objective information? Why or why not?
  4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
  5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Sample Solution

Abdominal Assessment

Description

Scholarly references should not be more than 5 years old.

Chief Complaint: “I have a pain in my stomach.”

Michael is a 17 year old male with a 16 hour history of intermittent epigastric and RLQ pain, which has increased in intensity over the last 4 hours. Currently, he is experiencing nausea and has vomited. He states that the pain started during football practice yesterday and was in the middle of his stomach. It bothered him overnight but noticed the pain was really bad about 6 AM when he was suppose to get up to go to school. He stated the pain had moved down to the lower right side of his abdomen.

Michael reported that his last meal was lunch at school yesterday and that he did not eat dinner last night because of the pain and nausea. He stated that he has taken some hits in football but this pain is worse. He states his last bowel movement was yesterday morning and was normal.

PMI
Childhood illnesses includes measles, mumps, rubella and varicella. Immunizations are up to date. Denies surgeries. He had a sports physical at the beginning of the season.

  1. Was all the necessary past medical history obtained? Were there any additional questions that should have been asked? If so what are they?
  2. Which portions of the physical examination will you perform? Why?
  3. What physical examination findings might you expect while examining this patient?
  4. What would be your list of differential diagnosis and which will be the diagnosis for this patient?

Sample Solution

ABDOMINAL ASSESSMENT

Description

Please NO plagiarism

Consider what history would be necessary to collect from the patient in the case study.
o Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Sample Solution