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.
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
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.
Please write this up as a narrative.
Use Subheadings to answer each part.
Do you need a similar assignment done for you from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount! Use Discount Code "Newclient" for a 15% Discount!
NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.
Open chat
Need Help?
Need Help? You can contact our live agent via WhatsApp +1(209)962-2652 Feel free to seek clarification on prices, discount, or any other inquiry.