Episodic Note Case Study: 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.  Assignment: Assessing the Abdomen A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping. Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen. In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions To Prepare Review the Episodic note case study your instructor provides you for this week’s Assignment.  · With regard to the Episodic note case study provided: o Review this week’s Learning Resources, and consider the insights they provide about the case study. o Consider what history would be necessary to collect from the patient in the case study. o 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? o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. The Assignment 1. Analyze the subjective portion of the note. List additional information that should be included in the documentatio.

1. Episodic Note Case Study:
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.
Assignment: Assessing the Abdomen
A woman went to the emergency room for severe abdominal
cramping. She was diagnosed with diverticulitis; however, as a
precaution, the doctor ordered a CT scan. The CT scan revealed
a growth on the pancreas, which turned out to be pancreatic
cancer—the real cause of the cramping.
Because of a high potential for misdiagnosis, determining the

2. precise cause of abdominal pain can be time consuming and
challenging. By analyzing case studies of abnormal abdominal
findings, nurses can prepare themselves to better diagnose
conditions in the abdomen.
In this Lab Assignment, you will analyze an Episodic note case
study that describes abnormal findings in patients seen in a
clinical setting. You will consider what history should be
collected from the patients as well as which physical exams and
diagnostic tests should be conducted. You will also formulate a
differential diagnosis with several possible conditions
To Prepare
Review the Episodic note case study your instructor provides
you for this week’s Assignment.
· With regard to the Episodic note case study provided:
o Review this week’s Learning Resources, and consider the
insights they provide about the case study.
o Consider what history would be necessary to collect from the
patient in the case study.
o 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?
o Identify
at least five
possible conditions that may be considered in a differential
diagnosis for the patient.
The Assignment

3. 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.
Resource for references
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.
Chapter 6, “Vital Signs and Pain Assessment”
This chapter describes the experience of pain and its causes.
The authors also describe the process of pain assessment.
Chapter 18, “Abdomen”

4. In this chapter, the authors summarize the anatomy and
physiology of the abdomen. The authors also explain how to
conduct an assessment of the abdomen.
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.
Credit Line: Advanced Health Assessment and Clinical
Diagnosis in Primary Care, 6th Edition by Dains, J.E.,
Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby.
Reprinted by permission of Mosby via the Copyright Clearance
Center.
Chapter 3, “Abdominal Pain”
This chapter outlines how to collect a focused history on
abdominal pain. This is followed by what to look for in a
physical examination in order to make an accurate diagnosis.
Chapter 10, “Constipation”
The focus of this chapter is on identifying the causes of
constipation through taking a focused history, conducting
physical examinations, and performing laboratory tests.
Chapter 12, “Diarrhea”
In this chapter, the authors focus on diagnosing the cause of
diarrhea. The chapter includes questions to ask patients about
the condition, things to look for in a physical exam, and
suggested laboratory or diagnostic studies to perform.
Chapter 29, “Rectal Pain, Itching, and Bleeding”

5. This chapter focuses on how to diagnose rectal bleeding and
pain. It includes a table containing possible diagnoses, the
accompanying physical signs, and suggested diagnostic studies.
Colyar, M. R. (2015).
Advanced practice nursing procedures.
Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition
by Colyar, M. R. Copyright 2015 by F. A. Davis Company.
Reprinted by permission of F. A. Davis Company via the
Copyright Clearance Center.
These sections below explain the procedural knowledge needed
to perform gastrointestinal procedures.
Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)
Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520)
Note:
Download this Student Checklist and Abdomen Key Points to
use during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Abdomen: Student checklist. In
Seidel's guide to physical examination: An interprofessional
approach
(9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.

6. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2019). Abdomen: Key points. In
Seidel's guide to physical examination: An interprofessional
approach
(9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th
Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.
S., & Stewart, R. W. Copyright 2019 by Elsevier Health
Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.
Document: Midterm Exam Review (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014).
DeGowin’s diagnostic examination
(10th ed.). New York, NY: McGraw Hill Medical.
Chapter 9, “The Abdomen, Perineum, Anus, and
Rectosigmoid” (pp. 445–527)
This chapter explores the health assessment processes for
the abdomen, perineum, anus, and rectosigmoid. This
chapter also examines the symptoms of many conditions in
these areas.
Chapter 10, “The Urinary System” (pp. 528–540)

7. In this chapter, the authors provide an overview of the
physiology of the urinary system. The chapter also lists
symptoms and conditions of the urinary system.