NURS 6512 Assessing the Abdomen

NURS 6512 Assessing the Abdomen

NURS 6512 Assessing the Abdomen

The abdominal compartment situated between the thorax and pelvis houses the gastrointestinal system as well as other organs such as the kidneys and spleen. The abdomen and the gastrointestinal system encounter physiologic disturbances resulting in several pathologies that range in severity from mild to life-threatening. Consequently, clinical assessment of the abdomen and gastrointestinal system is imperative to assist in prompt diagnosis of these pathologies and initiation of the necessary therapeutic approaches. This paper will explore a case study concerning LZ, a 65-year-old African American male who presents to the emergency department with a two-day history of epigastric pain radiating to the back. The subsequent paragraphs will explore subjective and objective details as well as the assessment of this case scenario.

Subjective

LZ presents with a sudden onset two-day history of intermittent epigastric pain that radiates to the back. The pain has persisted despite the use of proton pump inhibitors. However, he reports an increase in severity and vomiting although there is no associated fever or diarrhea. Epigastric abdominal pain is a non-specific symptom that may indicate both gastrointestinal and non-gastrointestinal etiologies. Consequently, further evaluation is required, and the additional history to inquire about the history of presenting illness includes the following: The character of the pain must be mentioned since some pathologies present with sharp pain while others present with a colicky pain. Similarly, it is important to ask about the timing of the pain. For instance, if it is worse at any particular time of the day. Factors aggravating and relieving the pain provide an important clue to the underlying etiology. Consequently, it is worth inquiring about the effects of a change of position on the pain. For instance, if it is worse or better in any distinct position. Similarly, noting the impact of eating on the pain is equally important.

Associated factors are crucial as most pathologies that present with epigastric pain also manifest with other symptoms. Apart from fever and diarrhea, questions regarding symptoms such as cough, chest pain, nausea, anorexia, hematuria, hematemesis, bloating, belching, nocturnal pain, indigestion, weight loss, dizziness, diaphoresis, anxiety, and alterations in bowel habits must be raised. LZ also vomited after taking his lunch. Subsequently, additional questions to ask include the number of episodes, constituents, amount, and the color of the vomitus, if other family members who ate the same meal vomited, and associated factors since vomiting is a non-specific symptom. Other parts of history that are considered significant include history of medication use particularly NSAIDs, steroids, and anticonvulsants among others, history of trauma, nutritional history including the diet and caffeine intake, and family history of similar presentation.

Additionally, LZ has a positive history of hypertension, hyperlipidemia, and GERD as well as a history of alcohol and smoking. The aforementioned factors are regarded as significant risk factors underlying several gastrointestinal pathologies. Consequently, it is important to quantify both smoking and alcohol intake and determine if the blood pressure and hyperlipidemia are well controlled. Finally, it is necessary to ask if he is stressed following divorce.

Objective

The analysis of the vital signs demonstrates that LZ with a blood pressure of 91/60 mmHg is hypotensive since he is a known hypertensive patient on metoprolol. Similarly, he is overweight which carries moderate health risks. The respiratory, dermatological, and cardiovascular systems revealed no abnormalities. Nevertheless, exhaustive examination with regards to inspection, palpation, auscultation, and percussion is crucial, particularly for the chest. auscultation particularly for the chest Findings noted on the abdominal exam include tenderness in the epigastric area with guarding although no masses or rebound tenderness. Additional features that are crucial to highlight in the physical examination include the general exam which focuses on the general appearance of the patient. Similarly, a detailed abdominal examination including comprehensive findings on auscultation, inspection, palpation, and percussion is crucial since different diseases present with different abdominal signs. Finally, a neurological examination is also significant as vomiting can be a manifestation of neurologic disease.

Assessment

Investigations necessary to assist in the diagnosis of his condition and rule out other causes of epigastric pain include both laboratory and radiological studies. Laboratory investigations include complete blood count with differential, urea, creatinine, and electrolytes, liver function tests, coagulation profile, serum amylase, and lipase levels, ESR/CRP, procalcitonin, blood glucose levels, LDH, lactate levels, serum triglycerides, calcium levels, stool for H. pylori antigen, and serum gastrin levels. The abovementioned laboratory tests are vital in evaluating the common causes of epigastric pain radiating to the back such as acute pancreatitis and peptic ulcer disease (Patterson et al., 2022).

On the other hand, imaging tests include ECG to rule out pericarditis, abdominal ultrasound to check for gallstones, liver or renal problems, abdominal X-ray which may reveal pneumoperitoneum in the case of a perforated ulcer, Chest X-ray and CT thorax, abdomen and Pelvis to identify possible pancreatitis and abdominal aortic aneurysm (Patterson et al., 2022). Finally, endoscopy is critical as both GERD and peptic ulcer disease are possible differentials.

Abdominal aortic aneurysm, acute pancreatitis, and perforated peptic ulcer are among the potential diagnosis for LZ’s presentation. Abdominal aortic aneurism refers to focal dilatation of the abdominal aorta to more than 1.5 times its ordinary diameter (Sakalihasan et al., 2018). Predisposing factors for this condition include advanced age, smoking, arterial hypertension, and hypercholesterolemia which LZ possesses (Sakalihasan et al., 2018). It is usually asymptomatic but may present with epigastric pain radiating to the back and pulsatile abdominal mass. A perforated peptic ulcer is another possible cause of his symptoms. Peptic ulcer disease shares similar risk factors as GERD including alcohol use and smoking. Psychological stress probably due to divorce is also a risk factor. The patient usually presents with epigastric pain which may radiate to the back. However, if perforated, features of peritonitis such as tenderness and guarding may be evident with no palpable mass (Malik et al., 2022). Acute pancreatitis similarly manifests with severe epigastric pain radiating to the back, abdominal tenderness, guarding, and nausea and vomiting (Shah et al., 2018). Additionally, LZ has a history of alcohol use and hyperlipidemia which may precipitate pancreatitis.

The other possible differential diagnoses for his condition include causes of acute abdomen particularly those causing epigastric pain such as acute mesenteric ischemia, myocardial infarction, acute gastritis, and Mallory Weiss syndrome (Patterson et al., 2022). For instance, acute mesenteric ischemia may present with epigastric pain, diarrhea, nausea and vomiting, and signs of peritonitis while Mallory Weiss syndrome manifests with epigastric pain/back pain, hematemesis, and signs of shock. Finally, myocardial infarction at times manifests as epigastric pain accompanied by nausea and vomiting, dizziness, dyspnea with exertion, and diaphoresis (Saleh & Ambrose, 2018). This is a potential differential diagnosis as LZ has risk factors for cardiovascular disease such as hypertension, smoking, alcohol use, and hyperlipidemia.

Conclusion

Meticulous evaluation of the abdominal and gastrointestinal systems is essential as it may point out an underlying diagnosis. Abdominal pain is a very non-specific symptom and may result from gastrointestinal or non-gastrointestinal causes. However, severe epigastric pain radiating to the back may be an indication of abdominal aortic aneurysm, acute pancreatitis, and perforated peptic ulcer.

References

Malik, T. F., Gnanapandithan, K., & Singh, K. (2022). Peptic ulcer disease. https://pubmed.ncbi.nlm.nih.gov/30521213/

Patterson, J. W., Kashyap, S., & Dominique, E. (2022). Acute Abdomen. https://pubmed.ncbi.nlm.nih.gov/29083722/

Sakalihasan, N., Michel, J.-B., Katsargyris, A., Kuivaniemi, H., Defraigne, J.-O., Nchimi, A., Powell, J. T., Yoshimura, K., & Hultgren, R. (2018). Abdominal aortic aneurysms. Nature Reviews. Disease Primers, 4(1), 34. https://doi.org/10.1038/s41572-018-0030-7

Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7, 1378. https://doi.org/10.12688/f1000research.15096.1

Shah, A. P., Mourad, M. M., & Bramhall, S. R. (2018). Acute pancreatitis: current perspectives on diagnosis and management. Journal of Inflammation Research, 11, 77–85. https://doi.org/10.2147/JIR.S135751

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. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• 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 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.

By Day 7 of Week 6

Submit your Lab Assignment.
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Week 6 Assignment 1

________________________________________
Exam: Week 6 Midterm Exam
This exam is a test of your knowledge in preparation for your certification exam. No outside resources, including books, notes, websites, or any other type of resource, are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.
This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. Prior to starting the exam, you should review all of your materials. This exam is timed with a limit of 2 hours for completion. When time is up, your exam will automatically submit.

By Day 7 of Week 6

Submit your Midterm Exam.
Submission and Grading Information
Submit Your Midterm Exam by Day 7 of Week 6.

To Complete this Exam:
Week 6 Exam

Week 6: Assessment of the Abdomen and Gastrointestinal System
On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?
Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.
This week, you will explore how to assess the abdomen and gastrointestinal system.

Learning Objectives

Students will:

Evaluate abnormal abdomen and gastrointestinal findings
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
• Analyze chest X-Ray and abdominal X-Ray imaging
• Identify concepts, theories, and principles related to advanced health assessment
________________________________________

Learning Resources

Required Readings (click to expand/reduce)

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”

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”
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 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.

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)

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Assessing the Abdomen

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.

Required Media (click to expand/reduce)

Assessment of the Abdomen and Gastrointestinal System – Week 6 (14m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_6_Assignment_1_Rubric
• Grid View
• List View
Excellent Good Fair Poor
With regard to the SOAP note case study provided, address the following:

Analyze the subjective portion of the note. List additional information that should be included in the documentation. Points Range: 10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation. Points Range: 7 (7%) – 9 (9%)
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation. Points Range: 4 (4%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation. Points Range: 0 (0%) – 3 (3%)

The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation. Points Range: 10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation. Points Range: 7 (7%) – 9 (9%)
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation. Points Range: 4 (4%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation. Points Range: 0 (0%) – 3 (3%)

The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not? Points Range: 14 (14%) – 16 (16%)
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation. Points Range: 11 (11%) – 13 (13%)
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation. Points Range: 8 (8%) – 10 (10%)
The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation. Points Range: 0 (0%) – 7 (7%)
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? Points Range: 18 (18%) – 20 (20%)
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis. Points Range: 15 (15%) – 17 (17%)

The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis. Points Range: 12 (12%) – 14 (14%)
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis. Points Range: 0 (0%) – 11 (11%)
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would be used to make a diagnosis.
· Would you reject or accept the current diagnosis? Why or why not?
· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature. Points Range: 23 (23%) – 25 (25%)

The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature. Points Range: 20 (20%) – 22 (22%)
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature. Points Range: 17 (17%) – 19 (19%)
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature. Points Range: 0 (0%) – 16 (16%)
The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. Points Range: 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. Points Range: 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors. Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.

CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”

History of Present Illness (HPI): JR is a 47-year-old Caucasian male who came to the hospital complaining of generalized abdominal pain which began three days before the present visit. He denies having taken any drug claiming that she had no idea of what to take. He claims that the severity of the pain currently is 5/10 but was worse of up to 9/10 for the past two days. She has been able to eat properly with the pain but complains of being nauseated afterward.

Medications: Lisinopril 10mg. Amlodipine 5 mg. Metformin 1g. Linctus 10 units qhs

Allergies: No known drug allergies

PMHx: HTN. Diabetes. She has a history of gastrointestinal bleeding which occurred four years ago

PSHx: No past surgical history

Sexual/Reproductive History: He is heterosexual and has three children, two boys, and one girl

Soc Hx: He is married and has three children, two boys, and one girl. Denies ever using tobacco. Confirms alcohol use occasionally.

Significant Fam Hx: He has three children, two boys, and one girl. No family history of colon cancer. The father had a history of type 2 diabetes mellitus and HTN. The mother has a history of HTN, GERD, and hyperlipidemia

Review of Systems:

General: He has been eating properly without any difficulties, despite nausea that comes afterward. He has no fever or loss of appetite.

HEENT: Denies itchy nose, palate, eyes, or ears. No problems with nose bleeding, hearing, ringing sound on the ears.

Skin: Intact skin with no lesions, itchiness, urticarial, Acne, Blistering, Dry skin, hives, Eczema, Moles, Nodules, skin oozing or skin cancer.

Respiratory: No coughing, shortness of breath or hemoptysis. CTA, the walls of her chest are well symmetrical. No history of asthma.

Cardiovascular/Peripheral Vascular: no heart murmurs, chest pain, accumulation of fluid or edema of the legs. Denies pain on palpitation or irregular heartbeats.

Gastrointestinal: Complains of severe generalized abdominal pain which has lasted for three days. Denies decreased in appetite. Confirms nausea after eating. Has a history of blood in stool, four years ago. Denies constipation, heartburn, hematemesis, or rectal bleeding.

Musculoskeletal:  No unsteady gait or deformities. Confirms having a full range of motion and an excellent bilateral strength in all extremities. Denies pain in the joints or fatigue.

Psychiatric: No anxiety, delusion, auditory/visual hallucinations, depressed mood, homicidal disorder, eating disorder, mental or physical abuse, suicidal thoughts or substance abuse.

Neurological: No difficulties in balance, fainting, coordination, or abnormality in gait. Denies loss of strength, or Tingling/Numbness symptoms.

OBJECTIVE DATA:  

P/E:

Vital signs: Temp 99.8; RR 16; BP 160/86; P 92; WT 248lbs; HT 5’10”; BMI 35

Pain: reports abdominal pain severity of 5/10 currently but 9/10 in the last two days. General: The patient is alert and well oriented. The patient can communicate clearly with no difficulties in answering all the questions asked. He maintains good hygiene and seems not to be anxious.

HEENT: pupils are equally dilated, round, bilaterally reactive to light with perfect accommodation. The extraocular movement is intact (EOMI). Clear auditory canal with an intact tympanic membrane. The light reflex presents bilaterally — no signs of enlarged tonsils or mouth wounds.

Skin: The skin is clean and moist, with no signs of scaling, itchiness or moles.

Chest: The thorax is perfectly symmetrical; there are no signs of gross rib deformity. The chest shape and expansion are normal.

Lungs: No diminishing breathing sounds noted, no rales or expiratory wheezes, no rhonchi, wet, and productive cough noted.

Heart:  The heart sounds are normal. No murmurs. Regular heart rate and rhythm. The heart rate is regular with the presence of S1, S2, and absence of S3 or S4.

Peripheral Vascular: No signs of edema, ulcers, varicose veins or deformities. No signs of pedal edema. 2+ dorsalis pedis pulses bilaterally confirmed.

Abdomen: generalized tenderness, hyperactive bowel sounds in all the four quadrants, severe pain on the LLQ. No signs of distention or hernia.

Musculoskeletal: Very steady gait with no deformities. Exhibits full range of motion in all extremities — no pain on movement of joints.

Neurological: Very alert and oriented in a good position. Tolerates appropriately to the tests performed — perfect tone with no history of neurological disorders.

Diagnostics: None

ASSESSMENT:

Pain in the Left lower quadrant of the abdomen.

Gastroenteritis– a viral or bacterial infection of the stomach and intestines causing irritations and inflammation of GI lining. Presents with symptoms such as watery diarrhea, nausea and vomiting, abdominal cramping and pain, fever, and a headache (Mayumi et al., 2016).

Current Diagnosis

The current diagnosis of gastroenteritis is inappropriate due to lack of enough information based on the provided data. It has been supported by limited objective and subjective data, which makes it unacceptable. The advanced practice nurse needs additional subjective and objective data in addition to proper diagnostic lab test result to make a firm diagnosis to avoid the high chances of misdiagnosis (Jamal et al., 2017). These lab tests will also make it possible to differentiate and rule out the following differential diagnosis:

1. Diverticulitis
2. Chron’s
3. Ulcerative colitis
4. Colon cancer
5. Gastroenteritis
6. Food poisoning

Diagnostic Tests Required

For proper diagnosis, the nurse in charge needs to order tests such as colonoscopy, stool occult test, liver function tests, biopsy, and CT scan when necessary. The stool occult tests will provide information confirming the cause of the GI bleeding. The liver function test, on the other hand, will measure the patient’s levels of alanine transferase, albumin, alkaline phosphate, aspartate aminotransferase, and bilirubin to rule out any injuries or liver infections (Othman et al., 2017). The CT scan will provide a proper visual of the abdomen to determine any injuries to any organ, or abnormal growth or any mass blockage within the abdomen. Lastly, the biopsy will determine the actual disease affecting a particular body tissue.

Differential Diagnosis

1. Diverticulitis: this is a chronic inflammatory condition or infection of small pouches known as diverticular which develop along the intestinal walls. This infection results in small abscess along the intestinal lining together with massive perforations of the bowel (Chuong et al., 2016). It results in cramping of the left side of the abdomen and diarrhea in addition to the presence of bright red blood in the patient’s stool, which is positive in the provided case. Other symptoms include fever, nausea, and
2. Chron’s: it is a type of inflammatory bowel disease caused by inflammation of the GI tract. It presents mostly with abdominal pain, severe diarrhea and bloody stool of which the patient is positive for (Zafar et al., 2015). Other sign and symptoms include fever, fatigue, mouth sores, anorexia, weight loss and fistula around the anal region.
3. Ulcerative colitis: It is an inflammatory condition of the colon, rectum or both areas, with ulceration of the colon lining (Bonovas et al., 2018). Patients with this condition usually complain of symptoms such as abdominal pain, severe diarrhea, and bloody stool just like the patient in the above case study. Other symptoms include rectal pain, the urgency to defecate, weight loss, fever, fatigue, and inability to defecate despite the urgency.

PLAN: N/A

References

Mayumi, T., Yoshida, M., Tazuma, S., Mizooka, M., Furukawa, A., Nishii, O., Shigematsu, K., … Hirata, K. (January 01, 2016). The Practice Guidelines for Primary Care of Acute Abdomen 2015. Japanese Journal of Radiology, 34, 1, 80-115.

Jamal, T. A., Edna, T.-H., Jamal, T. A., Edna, T.-H., Endreseth, B. H., Endreseth, B. H., & Lydersen, S. (January 01, 2017). Clinical diagnostic accuracy of acute colonic diverticulitis in patients admitted with acute abdominal pain, a receiver operating characteristic curve analysis. International Journal of Colorectal Disease, 32, 1, 41-47.

Othman, A. E., Bongers, M. N., Zinsser, D., Schabel, C., Wichmann, J. L., Arshid, R., Notohamiprodjo, M., … Bamberg, F. (April 13, 2017). Evaluation of reduced-dose CT for acute non-traumatic abdominal pain: evaluation of diagnostic accuracy in comparison to standard-dose CT. Acta Radiologica, 59, 1, 4-12.

Zafar, H. M., Chadalavada, S. C., Kahn, C. E., Cook, T. S., Sloan, C. E., Lalevic, D., Schnall, M. D., … Langlotz, C. P. (September 01, 2015). Code abdomen: An assessment coding scheme for abdominal imaging findings possibly representing cancer. Journal of the American College of Radiology, 12, 9, 947-950.

Chuong, A. M., Corno, L., Beaussier, H., Boulay-Coletta, I., Millet, I., Hodel, J., Taourel, P., … Zins, M. (January 01, 2016). Assessment of Bowel Wall Enhancement for the Diagnosis of Intestinal Ischemia in Patients with Small Bowel Obstruction: Value of Adding Unenhanced CT to Contrast-enhanced CT. Radiology, 280, 1, 98-107.

Bonovas, S., Lytras, T., Nikolopoulos, G., Peyrin-Biroulet, L., & Danese, S. (January 01, 2018). Systematic review with network meta-analysis: comparative assessment of tofacitinib and biological therapies for moderate-to-severe ulcerative colitis. Alimentary Pharmacology & Therapeutics, 47, 4, 454-465.

Total Points: 100
Name: NURS_6512_Week_6_Assignment_1_Rubric