Assessing the Abdomen Abdominal Assessment Walden University NURS 6512: ADVANCED HEALTH ASSESSMENT AND DIAGNOSTIC REASONING January 2, 2019
Assessing the Abdomen SOAP CHARTING Initials: CD Age: 47 Sex: Male Race: Caucasian S 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. Current Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units QHS Allergies: NKDA PMHx: HTN, Diabetes, hx of GI bleed 4 years ago Soc Hx:. Denies tobacco use; occasional ETOH, married, 3 children (1 girl, 2 boys) Fam Hx: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD O.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, positive pain in the LLQ on palpation 2
Assessing the Abdomen Diagnostics: None A. Differential Diagnoses: Left lower quadrant pain, Gastroenteritis Is the Current Diagnosis Supported by the Current Information? The diagnosis of Gastroenteritis cannot be supported by clinical presentations of symptoms. The provider (APRN) will need additional subjective and objective data, to provide a complete assessment and evaluation. There will be diagnostic tests and lab work warranted to exclude out other possible diagnoses. Additional Subjective Information Needed The client is ambiguous and vague regarding his abdominal pain. The history failed in providing the exact location of his abdominal pain. The client rated his pain 5/10 out of scale 0 to 10, with 0 being no pain and 10 being the worst. However, the client did not define the pain he is feeling. (i.e., sharp, cramping, aching, shooting, stabbing or throbbing, etc). Does it “come and go? Or is all the time” (chronic, sporadic or acute) what was the client doing ? Are there any foods or activities that aggravate the pain? Are there any alleviating factors such as flatulence eructation or defecating? any problems with urinating frequency, hesitancy, odor? Any recent traumas? Any contact with flu or colds? Any recent travel within or outside the country? (Rule out CMV cytomegalovirus, Hepatitis or malaria). Not only does the provider need more information regarding the chief complaint. The provider also needs the subjective review of systems (ROS) to complete a proper examination.
- Spring '19
- Bowel obstruction