solved Abdominal Assessment Case Study SOAP Note Subjective: CC: “My stomach

Abdominal Assessment Case Study SOAP Note
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

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
The Assignment Instructions
Do this assignment in narrative form and not SOAP note form. Please follow the rubric.

Analyze the subjective      portion of the note. List additional information that should be included      in the documentation.
Analyze the objective      portion of the note. List additional information that should be included      in the documentation.
Is the assessment      supported by the subjective and objective information? Why or why not?
What diagnostic tests      would be appropriate for this case, and how would the results be used to      make a diagnosis?
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.