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Assessment of the Abdomen and Gastrointestinal System
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.
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