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Episodic Note Case Study – My Nursing Experts

Episodic Note Case Study – My Nursing Experts

ABDOMINAL ASSESSMENTSubjective:CC: “My stomach hurts, I have diarrhea and nothing seems to help.”HPI: MT, 45 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 agoMedications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units phsAllergies: NKDAFH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERDSocial: 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 248lbsHeart: RRR, no murmursLungs: CTA, chest wall symmetricalSkin: Intact without lesions, no urticariaAbd: soft, hyperactive bowel sounds, pos pain in the LLQDiagnostics: NoneAssessment:Left lower quadrant painGastroenteritisDirections for assignment ( all aspects of instructions to be included).1. Analyze the subjective portion of the note.2. List additional information that should be included in the documentation.3. Analyze the objective portion of the note.4. List additional information that should be included in the documentation.5. Is the assessment supported by the subjective and objective information? Why or why not?6. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?7. Would youreject/acceptthe current diagnosis? Why or why not? Identify five possible conditions that may be considered as a differential diagnosis for this patient.8. Explain your reasoning using at leastfour different referencesfrom current evidence-based literature.9. Identifyat least fivepossible conditionsthat may be considered in adifferential diagnosisfor the patient.


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