Abdominal Assessment

In this assignment, you will analyze a SOAP 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. Abdominal Assessment SUBJECTIVE: • CC: “My lower back hurts after transferring a patient from bed to his wheelchair.” • HPI: TO, 42 yo Caucasian female, complains of having lower back pain that started 2 days ago. she has taken tylenol 650mg Q8hr as needed. she states the pain is a 5/10 today but has been as much as 9/10 when it first started. • PMH: HTN, Diabetes, GERD • Medications: Lisinopril 5mg, Amlodipine 2.5 mg, Metformin 500mg QD, Lantus 10 units subcutaneous qhs, Omeprazole 20mg QAm • Allergies: NKDA • FH: Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD • Social: Denies tobacco use; occasional etoh, married with 2 children (1 girl, 1 boy) OBJECTIVE: • VS: Temp 98.8; BP 124/62; RR 20; P 78; HT 5’2”; WT 169lbs • 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: • lower back pain • Gastroenteritis PLAN: To prepare: With regard to the SOAP 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 three possible conditions that may be considered in a differential diagnosis for the patient. To complete: • Subjective: What details did the patient provide regarding his or her personal and medical history? • Objective: What observations did you make during the physical assessment? • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies? • Reflection notes: What would you do differently in a similar patient evaluation?