NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

Walden University NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

 

How to Research and Prepare for NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

 

Whether one passes or fails an academic assignment such as the Walden University  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

 

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

 

How to Write the Introduction for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

 

The introduction for the Walden University  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

 

How to Write the Body for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen 

 

After the introduction, move into the main part of the  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

 

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

 

How to Write the Conclusion for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

 

How to Format the References List for  NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

Gastrointestinal disorders are common encounters in nursing practice with considerable public health impacts. Nurses and other healthcare providers should perform comprehensive history taking and physical examinations to develop accurate diagnoses and care plans. Therefore, this essay examines J.R.’s case study. J.R. presented to the hospital with complaints of having generalized abdominal pain that began three days ago. He has been experiencing diarrhea that has been unresponsive to any treatments adopted by the patient.  The essay analyzes additional subjective and objective information that should be obtained from the client if subjective and objective data supports the assessment, diagnostic tests, and possible differential diagnoses.

Additional Subjective Information

Additional subjective information should be obtained to guide the development of an accurate diagnosis. First, information about the things that might have led to the abdominal pain should be obtained. This includes data such as diet, alcohol consumption, or possible trauma that could have led to the symptoms. Information about previous experiences of stomach pain should also be obtained. A previous history of stomach pain will help the nurse determine if the condition is acute or chronic. In addition, the nurse should determine if JR experienced a similar pain when he experienced gastrointestinal bleeding four years ago. Information on previous treatments for the GI bleed should be obtained to guide the current management. The nurse should also seek information about the characteristics of stomach pain (Maret-Ouda et al., 2020). For example, information on whether the pain radiates elsewhere should have been obtained to rule out causes such as pancreatitis.

Information about the character of the diarrhea should also be obtained. Information such as blood-stained diarrhea would help the nurse to develop a potential diagnosis of gastrointestinal tract bleeding. Associated symptoms such as vomiting should also be obtained. This is important because symptoms such as projectile vomiting will indicate potential problems such as pyloric stenosis. Information about changes in the client’s weight over the past few months should also be obtained. Unintentional weight loss could indicate other health problems such as cancer of the gastrointestinal system. Information on changes in appetite should also be sought. Early satiety could indicate problems such as hypertrophic pyloric stenosis. The nurse should also obtain information about the factors that relieve, precipitate, or worsen the stomach pain. For example, a diagnosis of peptic ulcer disease will be made if the symptoms worsen 15-30 minutes after eating (Sverdén et al., 2019). A diagnosis of gastroesophageal reflux disease will be made if the symptoms worsen when JR lies down and improves with sitting upright.

Subjective Portion Analysis

Appropriate clinical diagnosis and the development of personalized treatment plans for specific patients need a rigorous healthcare assessment. As such, more information on the nature of patient LZ’s pain is needed.  What are the characteristics and severity of the client’s pain? What triggered the onset of the pain? Was it a progressive pain, or did he suddenly feel the effects of the pain? This necessitates a thorough examination of the patient’s symptoms to determine what kind of pain he is experiencing (Ball et al., 2017). It is important for the practitioner to get further information about the conditions that have caused the pain to increase or intensify. Other questions that a clinician should ask include: How would you rate your current level of pain? What is the highest number on a scale of one to ten? Is there any medicine you’ve taken in the last week? Have you had any surgical procedures performed on you? Do you experience greater pain when you are lying down than when you are sitting upright?

Objective Portion Analysis

There are critical things missing from the soap note when it comes to the objective information. The overall appearance of the client must be described in the objective component of the note.  It is also necessary to record the patient’s level of consciousness. The findings of any laboratory tests performed, such as abdominal ultrasound and CT scan should be documented. Apart from the vital signs, heart, lungs, skin, and abdomen evaluation, the practitioner should additionally incorporate the client’s facial expression while assessing his painful area, the color of his skin, abdominal bloating, and whether or not he has excessive sweating.

Is the assessment supported by subjective and objective information?

The assessment is supported by the subjective and objective data. The patient has a history of abdominal pain that has become more severe over time, and he has also vomited. Furthermore, he reports pain in the epigastric region and guarding, which is in line with abdominal pain. Diagnostic tests such as the ultrasound and CT scan might provide additional findings to validate the assessment.

 Appropriate Diagnostic Tests

In order to determine the presence of infection and bleeding, a complete blood count will be required. Amylase and

lipase tests are also required since a high lipase level in the presence of a normal amylase level indicates that pancreatitis is unlikely to be the cause. Abdominal ultrasonography is the most often used diagnostic to identify abdominal aortic aneurysms, perforated ulcers, and other abdominal abnormalities. It will also be essential to perform an abdominal CT scan, which is a non-invasive examination that employs X-rays to make cross-sectional pictures of the components within the abdominal region. An endoscopy will be performed to evaluate the upper digestive tract, and a abdominal/chest X-ray will be taken since air beneath the diaphragm may indicate a perforated ulcer.

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 Reject/Accept the Current Diagnosis

I accept the diagnosis of acute pancreatitis; however I disagree with the diagnoses of abdominal aortic aneurysm and perforated ulcer. The symptoms of abdominal aortic aneurysm include abdominal pain, leg pain, and a pulsating belly. However, these indications are not apparent in this case, and as a result, I reject. I also reject the diagnosis of perforated ulcer since the pain linked with this condition does not spread to the back.

Three Possible Conditions

• Acute Pancreatitis:Acute pancreatitis is defined as pancreatic inflammation that occurs suddenly (Mederos et al., 2021). The most common symptom is abdominal pain. It normally subsides after a few days, although it may often become serious and life-threatening. Gallstones and excessive alcohol use are the two most prevalent causes of acute pancreatitis.
• Cholecystitis:Cholecystitis is a condition in which the gallbladder becomes inflamed. It is often caused by gallstones obstructing the tube coming from the gallbladder. This leads in an accumulation of bile, which might result in inflammation. Some of the other possible causes of cholecystitis include abnormalities with the bile ducts or tumors, as well as acute disease and some infections (Balmadrid, 2018). Right upper abdominal pain, soreness in the right shoulder, vomiting, nausea, and, on rare occasions, fever are all symptoms of this condition. Prescription painkillers (PPIs) do not alleviate the pain.

Gastritis: Gastritis is a term that refers to a range of illnesses that are characterized by inflammation of the stomach’s lining. Gastritis is most commonly caused by infection with the same bacteria that cause most gastrointestinal ulcers, or by the persistent use of certain pain medications such as aspirin. Upper stomach pain, vomiting, and nausea are some of the symptoms. Symptoms may not appear at all in other cases.

References

Azer, S. A., & Akhondi, H. (2019). Gastritis. https://europepmc.org/article/nbk/nbk544250

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s Guide to

Balmadrid, B. (2018). Recent advances in management of acalculous cholecystitis. F1000Research, 7, 1660. https://doi.org/10.12688/f1000research.14886.1

Mederos, M. A., Reber, H. A., & Girgis, M. D. (2021). Acute pancreatitis. JAMA, 325(4), 382. https://doi.org/10.1001/jama.2020.20317

Sample Answer 2 for NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

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.

Sample Answer 3 for NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

The SOAP note’s 65-year-old Black American male patient arrives at the emergency room complaining of sporadic epigastric stomach ache that radiates to his back. When he went to the neighboring urgent care facility, PPIs were provided to him without providing any relief. The patient reported that the pain had been worse over the preceding few hours and he had vomited the afternoon when he finally went to the emergency department. He hasn’t had a fever, diarrhea, or any other signs often associated with stomach discomfort. The purpose of this paper is to demonstrate how to evaluate the offered subjective and objective data to determine the patient’s primary and differential diagnoses.

Subjective Portion

According to the OLDCARTS technique, the HPI lacks information on the kind, intensity, and aggravating and alleviating elements of the pain. In addition, there is no information on the color or consistency of vomit (Ball et al., 2019).The date of the HTN diagnosis and if the illness has been treated are missing from the PMH. This section ID also lacks information on previous hospitalizations and surgical histories. The dosage and frequency of metoprolol are not listed in the medication section. The allergy section does not address allergies to food, the environment, or latex. A family history should include information on all first-degree relatives, including parents, grandparents, siblings, and their children. Add details on the person’s age, whether they’re living or deceased, and how they’re feeling. Any dead relatives’ age and method of death should also be mentioned. Age and any ailments should be mentioned if the person is still alive. It should also include a list of mental health issues including depression, addiction, and substance misuse.

Owing to the patient’s digestive issues, a comprehensive series of subjective GI system questions should be made, including Has the digestive illness continued for a considerable amount of time? Burning in the substernal area or the chest? Does your tummy hurt? struggling to swallow? Does swallowing hurt? Is it vomiting or nausea? abdominal bloating or distention? Have yellow skin (jaundice)? vomiting that is hemorrhagic (hematemesis)? stool that is dark or tarry? Scratched stools? Constipation? diarrhea or other alterations to bowel habits (Weledji, 2020). Patients do not receive Hepatitis A or B vaccines.

Objective Portion

The general assessment of the patient is not standardized. The vital signs section does not include the patient’s oxygen saturation or BMI. Every recent journey should be taken into account to assess GI problems related to travel. The physical exam of the skin should cover any skin changes, notably any yellowing that would suggest jaundice from cholestasis (Ball et al., 2019). Since changes in urine color can be an indication of cholestasis, a disorder in which the kidneys eliminate direct bilirubin from the serum, this topic belongs under the genitourinary area.

When a patient complains of stomach pain, nausea, and/or vomiting, the Gastrointestinal system should be thoroughly evaluated. The four quadrants of the abdomen should be evaluated using sonography, percussion, and palpation, as well as objective data from examining and assessing the abdomen for shape, scars, pigmentation, symmetry, and abnormal protrusions. Because cholestasis may be associated with pale-colored feces, stools should be inspected for color. Blood in the stool is investigated to rule out GI hemorrhage (Gallaher & Charles, 2022). Variations in appetite, nutrition, or food consumption must be taken into consideration in this assessment. For evaluating organ performance, it is essential to get the missing laboratory results.

Assessment Supported

A history of alcohol consumption supports the diagnosis of pancreatitis in the context of symptoms such as nausea, vomiting, and epigastric pain that radiates to the back (Hamm, 2021). Other tests to support pancreatitis diagnosis include elevated amylase and/or lipase levels that are 3 times higher than the upper limit of normal. Moreover, the CT ought to back up this diagnosis.

This diagnosis of AAA is unsupported because the patient in this case seems stable and lacks several of the crucial presenting symptoms. This diagnosis necessitates figuring out whether or not the AAA is raptured based on the symptoms that are now present. The majority of cases with AAA are undiagnosed and asymptomatic (Weledji, 2020). The initial imaging procedure necessary for this diagnosis, if the patient is not allergic to contrast or pregnant, is a CT scan with contrast.

A perforated ulcer is not supported by either subjective or objective facts. A burst peptic ulcer is identified by the classic trifecta of sudden onset of abdominal rigidity, tachycardia, and stomach distress. Both the patient’s heart rate and the abdomen are not tachycardic (Ball et al., 2019). A history of smoking is the only risk factor for PUD; the patient does not use any NSAIDS or steroids.

Diagnostic Tests

Many medical conditions can cause abdominal discomfort, and numerous tests may be necessary to identify the reason. In addition to a health history and physical exam, laboratory tests for blood, urine, stool, and enzymes may be utilized to aid in diagnosis. Abdominal abnormalities can also be found with imaging tests (Ball et al., 2019). Diagnostic tests will include an Electrocardiogram, which would disclose any aberrant cardiac findings and exclude ischemia due to the patient’s specific presentation of stomach discomfort.

Blood tests including the Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), and stool samples for magnesium and phosphorus are examples. To completely rule out an infection, they are crucial (Weledji, 2020). As the patient complains of frequently having diarrhea, the CMP would provide a current health status of the kidneys, liver, and electrolytes. Test for Liver Enzymes and Hepatic Function These examinations reveal how well the liver is working. This examination will demonstrate if the liver is successfully removing the body’s toxins, which may result in severe stomach discomfort. This is crucial because a portion of the liver can be found in the epigastric region 4.

Rejection or Acceptance

Unless more testing is done, I would not accept the diagnosis of AAA. While this patient complains of sporadic discomfort, his vital signs are stable, and even though individuals with AAA frequently arrive with tearing or ripping chest pain, this patient does not characterize his pain in such terms(Hafeez et al., 2018).

The major diagnosis is acute pancreatitis, which I accept. Hafeez et al. (2018) claim that acute pancreatitis may be diagnosed initially without the use of imaging and that the presence of stomach discomfort together with high lipase or amylase levels can help to confirm this diagnosis. Also, the patient has a known etiology such as alcoholism and hyperlipidemia (Grigorian et al., 2019).

Possible Conditions

Gastritis may be the cause of the abrupt onset of epigastric discomfort, nausea, and vomiting (Weledji, 2020). It could be brought on by elements like smoking and drinking, which LZ’s past demonstrates. The patient might additionally have gastritis as a result of stress, such as losing his job.

Ulcer perforation: For two days, the patient’s condition, such as stomach pain, grew worse. This is how ulcer perforation presents. From modest stomach aches to severe agony and tachycardia, it goes through many stages (Yamamoto et al., 2018). H. pylori infection or regular use of NSAIDs, which can damage the stomach lining, maybe the cause of this.

Cholecystitis causes the gallbladder to swell up. With nausea, purging, and fever as their accompanying symptoms, biliary colic is an increasing pain in the right upper quadrant that may progress to the back (Gallaher & Charles, 2022). Jaundice is evident depending on the degree of gallbladder neck obstruction. The attack typically happens after a large, fatty meal. The pain eventually develops into a little upper-right stomach discomfort or a nagging ache. Abdominal ultrasound can identify calcified gallstones, and elevated white blood cell counts in the test findings can help to make the diagnosis.

Conclusion

The 65-year-old Black American male patient is likely suffering from gastritis. This may be the cause of the abrupt onset of epigastric discomfort, nausea, and vomiting.In addition to the pertinent lab testing to rule out the differential diagnosis, additional findings that might assist corroborate this diagnosis have been noted above. Correct diagnosis is essential for fostering the creation of the most efficient care strategy.

 

 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.ISBN: 9780323545389

Gallaher, J. R., & Charles, A. (2022). Acute Cholecystitis: A Review. JAMA, 327(10), 965–975. https://doi.org/10.1001/jama.2022.2350

Grigorian, A., Lin, M. Y., & de Virgilio, C. (2019). Severe epigastric pain with nausea and vomiting. Surgery, 227–237. https://doi.org/10.1007/978-3-030-05387-1_20

Hafeez, A., Karmo, D., Mercado-Alamo, A., & Halalau, A. (2018). Aortic dissection presenting as acute pancreatitis: Suspecting the unexpected. Case Reports in Cardiology, 2018, 1–4. https://doi.org/10.1155/2018/4791610

Hamm, R. G. (2021). Acute Pancreatitis: Causation, Diagnosis, and Classification Using Computed Tomography. Radiologic Technology, 93(2), 197CT219CT. https://pubmed.ncbi.nlm.nih.gov/34728586/

Weledji, E. P. (2020). An Overview of Gastroduodenal Perforation. Frontiers in Surgery, 7. https://doi.org/10.3389/fsurg.2020.573901

Yamamoto, K., Takahashi, O., Arioka, H., & Kobayashi, D. (2018). Evaluation of risk factors for perforated peptic ulcer. BMC Gastroenterology, 18(1). https://doi.org/10.1186/s12876-018-0756-4

Sample Answer 4 for NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen

The SOAP note concerns a 47-year-old white man with chief complaints of abdominal pain and diarrhea. He has had generalized abdominal pain for three days but has not taken any meds to relieve the pain. He reports that the pain was initially at 9/10 but has reduced to 5/10, and he cannot eat due to ensuing nausea. His medical history is positive for

hypertension, DM, and GI bleeding. GI exam findings include a soft abdomen, hyperactive bowel sounds, and LLQ pain. The purpose of this paper is to analyze the SOAP note, identify appropriate diagnostic tests, and discuss likely diagnoses.

Subjective Portion

The SOAP note’s HPI describes the abdominal pain, including the onset, location, associated symptoms, and severity of pain. Nevertheless, the HPI should have given an additional description of the abdominal pain, particularly the duration of the abdominal pain, timing (before, during, or after meals), and frequency. In addition, the characteristics of the abdominal pain should be included describing if the pain is sharp, crampy, dull, colicky, diffuses, constant, or radiating (Sokic-Milutinovic et al., 2022). In addition, the HPI should have included the exacerbating and alleviating factors for the abdominal pain and to what level the alleviating factors relieve the pain. Furthermore, the HPI has described only the abdominal pain leaving out diarrhea. It should describe diarrhea, including the onset, timing, frequency, characteristics of the stools (watery, mucoid, bloody, greasy, or malodorous), and relieving and aggravating factors.

The subjective part should have included the patient’s immunization status with a focus on the last Tdap, Influenza, and COVID shots and surgical history. The social history has scanty information and should have included the patient’s education level, occupation, current living status, hobbies, exercise and sleep patterns, dietary habits, and health promotion interventions (Gossman et al., 2020). Lastly, a review of systems (ROS) is mandatory for a SOAP note. Thus, the SOAP note should have a ROS that indicates the pertinent positive and negative symptoms in each body system, which helps identify other symptoms the patient has not reported in the HPI.

Objective Portion

The objective part misses critical information like the findings from the general assessment of the patient, which should include the client’s general appearance, personal hygiene, grooming, dressing, speech, body language, and attitude towards the clinician. In addition, findings from a detailed abdominal exam should have been provided. For instance, it should have inspection findings, including the abdomen’s pigmentation, respiratory movements, symmetry, contour, and presence of scars. Additional auscultation findings that should be indicated include the presence of friction ribs, vascular sounds, and venous hum. It should also have exam findings from palpation and percussion, including abdominal tenderness, masses, organomegaly, guarding, or rebound tenderness (Sokic-Milutinovic et al., 2022). Besides, the liver span and spleen position should be indicated.

Assessment

The assessment findings identified in the SOAP note are Left lower quadrant (LLQ) pain and gastroenteritis (GE). LLQ pain is supported by subjective findings of abdominal pain and LLQ tenderness on exam. GE is consistent with subjective data of diarrhea, abdominal pain, and nausea and objective data of low-grade fever of 99.8 and hyperactive bowel sounds, which are classic symptoms.

Diagnostic Tests

The appropriate diagnostic tests for this patient are stool culture, complete blood count (CBC), and abdominal ultrasound. A stool culture is crucial to look for ova and cyst, which will help establish the causative agent for diarrhea and guide the treatment plan. Based on the WBC count, the CBC will establish if the patient has an infection and if the infection is bacterial or viral (Sokic-Milutinovic et al., 2022). The abdominal ultrasound will be used to visualize abdominal organs and identify if there is inflammation that could be contributing to the patient’s GI symptoms.

Differential Diagnoses

I would accept the GE diagnosis because it is consistent with the patient’s clinical features of diarrhea, generalized abdominal pain, nausea, low-grade fever, hyperactive bowel sounds, and abdominal tenderness. Nevertheless, I would reject LLQ pain as a diagnosis because it is a physical exam finding and does not fit the description of a medical diagnosis. The likely diagnoses for this case are:

Acute Viral Gastroenteritis

Viral GE is an acute, self-limiting diarrheal disease caused by viruses. The common causative viruses are rotavirus, norovirus, enteric adenovirus, and astroviruses. Clinical manifestations include anorexia, nausea, vomiting, watery diarrhea, abdominal pain/tenderness (mild to moderate), low-grade fever, dehydration, and hyperactive bowel sounds (Orenstein, 2020). Acute Viral GE is a presumptive diagnosis due to the patient’s clinical manifestations of nausea, diarrhea, abdominal pain, mild fever, abdominal tenderness on palpation, and hyperactive bowel sounds.

Ulcerative Colitis (UC)

UC is a chronic inflammatory and ulcerative GI disorder that occurs in the colonic mucosa and is characterized by bloody diarrhea. Clinical symptoms include mild lower abdominal pain, bloody diarrhea, and bloody mucoid stools. Systemic manifestations include anorexia, nausea, fever, malaise, anemia, and weight loss (Porter et al., 2020). The patient’s positive findings of nausea, diarrhea, abdominal pain, and mild fever, as well as a history of GI bleeding, makes UC a likely diagnosis.

Colonic Diverticulitis

Diverticulitis presents with inflammation of a diverticulum with the presence or absence of infection. Abdominal pain is the primary symptom of colonic diverticulitis. Patients present with LLQ abdominal pain and tenderness, which can sometimes be suprapubic and often have a palpable sigmoid. The abdominal pain is usually accompanied by fever, nausea, vomiting, and occasionally urinary symptoms (Swanson & Strate, 2018). Peritoneal signs like rebound and guarding can occur, especially with abscess or perforation. Colonic diverticulitis is a probable diagnosis based on nausea, mild fever, and LLQ pain findings.

Conclusion

The HPI in the objective portion should have described the characteristics of the abdominal pain and stated the onset, frequency, characteristics, and timing of diarrhea. A ROS should also be included with the patient’s positive and negative symptoms. The objective part should have detailed physical exam findings from a detailed abdominal exam. Diagnostic tests should include stool culture, CBC, and abdominal U/S. The likely diagnoses are Vital GE, Ulcerative colitis, and colonic diverticulitis.

References

Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing.

Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1

Porter, R. J., Kalla, R., & Ho, G. T. (2020). Ulcerative colitis: Recent advances in the understanding of disease pathogenesis. F1000Research, 9, F1000 Faculty Rev-294. https://doi.org/10.12688/f1000research.20805.1

Sokic-Milutinovic, A., Pavlovic-Markovic, A., Tomasevic, R. S., & Lukic, S. (2022). Diarrhea as a Clinical Challenge: General Practitioner Approach. Digestive Diseases, 40(3), 282-289. https://doi.org/10.1159/000517111

Swanson, S. M., & Strate, L. L. (2018). Acute Colonic Diverticulitis. Annals of Internal Medicine, 168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010

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