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

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
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

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