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

To Prepare
Review the Episodic note case study your
instructor provides you for this week’s Assignment. Please see the “Course
Announcements” section of the classroom for your Episodic note case study.
With regard to the Episodic note case study provided:

Review this week’s Learning
Resources, and consider the insights they provide about the case study.
Consider what history would
be necessary to collect from the patient in the case study.
Consider what physical
exams and diagnostic tests would be appropriate to gather more
information about the patient’s condition. How would the results be used
to make a diagnosis?
Identify at least
five possible conditions that may be considered in a
differential diagnosis for the patient.

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.

CASE STUDY: 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

PLAN: This section is not required for the assignments in this course
(NURS 6512) but will be required for future courses.

Required reading/Resources:

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S.,
& Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

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