The Assignment
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.
Assignment 1: Lab Assignment: Assessing the Abdomen
ABDOMINAL ASSESSMENT
Subjective:
CC: “My stomach has been hurting for the past two days.”
HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.
PMH: HTN
Medications: Metoprolol 50mg
Allergies: NKDA
FH: HTN, Gerd, Hyperlipidemia
Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female
Objective:
VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
Diagnostics: US and CTA
Assessment:
Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
