Assessing the Abdomen

Assessing the Abdomen

Work type:         Case study

Format:                APA

Pages:   3 pages ( 825 words, Double spaced

Academic level:                Undergrad. (yrs 3-4)

Subject or discipline:      Nursing

Title:      Abdominal Assessment

Number of sources:        3

Paper instructions:

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: None

 

Assessment:

 

  • Left lower quadrant pain

 

  • Gastroenteritis

 

Please review paper attached as an example