Health Assessment

In this Assessment 1 Assignment, you will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Just add in what you want to this case to make it unique to you. Do not use NA or normal.

ABDOMINAL ASSESSMENT

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: ?

Assessment:

Left lower quadrant pain

Gastroenteritis