What diagnostic tests would be appropriate for the case

Reference no: EM132566419

Assignment: 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

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.

2. Analyze the objective portion of the note. List additional information that should be included in the documentation.

3. Is the assessment supported by the subjective and objective information? Why or why not?

4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

5. 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.

6. Please write this up as a narrative.

7. Use Subheadings to answer each part.

Reference no: EM132566419

Questions Cloud

What is the johnson amendment : What is the "Johnson Amendment?" Explain its history, as well as the arguments pro and con regarding it.

How professional standard of practice should be demonstrated : In this assignment, you will be writing a 1,000-1,250 word paper describing the differing approaches of nursing leaders and managers to issues in practice.

Damage and building requirements in your community : You will focus on structural damage and building requirements in your community. This can include actions taken to protect against earthquakes.

What is the dollar amount of outstanding performance : What is the dollar amount of outstanding performance obligations that Peter should report related to this contract in his December 31, 2019 financial statements

What diagnostic tests would be appropriate for the case : 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?

Calculate accumulated depreciation over six years : Genetic Insights Co. purchases an asset for $12,264. Calculate accumulated depreciation over 6 years. Round the answer to two decimals.

What is the amount reported for the building : What is the amount reported for the building (i.e. Acquisition Cost less any Accumulated Depreciation and Write-Downs) on WheeWork's June 30, 2020 Balance Sheet

Write a description of your core values : Develop and submit a personal leadership philosophy that reflects what you think are characteristics of a good leader. Use the scholarly resources on leadership

Criminal trial preparation-law enforcement community : Drug seizure laws have come into prominence in the United States. When a drug arrest is completed, the law enforcement community

User Account

All Pages