The Assignment
● 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.
Week 6 Introduction
Posted on: Saturday, January 2, 2021 10:24:44 PM EST
This week, you will explore how to assess the abdomen and
gastrointestinal system.
Learning Objectives
Students will:
● Evaluate abnormal abdomen and gastrointestinal findings
● Apply concepts, theories, and principles relating to health
assessment techniques and diagnoses for the abdomen and
gastrointestinal system
● Identify concepts, theories, and principles related to
advanced health assessment1. Read the Syllabus- You can
find it under the “Syllabus” tab.
- Readings- Read week 6 -course material.
- Late Policy: Students are expected to submit assignments by the
due dates noted in the course. In extenuating circumstances, such
as illness, the student must contact the Instructor as soon as
possible to discuss the situation. In those circumstances, the
faculty will determine the appropriate course of action for the
student. Depending on the situation, these actions may include
recommendations to drop the course (if within the University
drop/withdrawal period), acceptance of some or all of the overdue
assignments with or without penalties, or failure to accept
assignments.
Assignments submitted late without the prior agreement of the
Instructor, outside of an emergency absence, or in violation of
agreements for late submission, will receive a grade reduction for
the assignment amounting up to 20%. After 5 days, the assignment
will not be graded. Students should be aware that late assignments
may not receive the same level of written feedback as do
assignments submitted on time.
Due this week:
Assignment 1: Lab Assignment: Assessing the Abdomen
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 afterward.
● 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.
