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Assignment: NURS 6512 Assessing the Abdomen

Assignment: NURS 6512 Assessing the Abdomen

Assignment NURS 6512 Assessing the Abdomen

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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.Assignment NURS 6512 Assessing the Abdomen

With regard to the Episodic note case study provided:

Review this week’s Learning Resources, and consider the insights they provide about the case study.

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

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 five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Analyze the objective portion of the note. List additional information that should be included in the documentation.

Is the assessment supported by the subjective and objective information? Why or why not?

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

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.

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.

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The SOAP note portrays a 65-year-old man who comes to the ED with a chief complaint of abdominal pain for the past two years. He has intermittent epigastric abdominal pain radiating to the back. The abdominal pain has worsened over the past hours, and he had one episode of vomiting after lunch. Physical exam findings include abdominal tenderness in the epigastric area with guarding but no abdominal mass or rebound present. The assessment findings are Abdominal Aortic Aneurysm (AAA), Perforated Ulcer, and Pancreatitis. The purpose of this assignment is to analyze the SOAP note and discuss the differential diagnoses for this case. 

Subjective Portion 

The HPI lacks information describing abdominal pain, like crampy, sharp, colicky, or dull. It should also have information on when the abdominal pain occurs, like pre- or post-prandial. Information on the abdominal pain relieving and aggravating factors should also be included (Rastogi et al., 2019). Besides, the HPI should have pain severity obtained by asking the patient to rate the pain on a pain rating scale. In addition, the subjective portion should have included the patient’s surgical history with dates of surgery and immunization history with dates of the last Flu and Tdap shots. Furthermore, the subjective portion lacks a review of systems (ROS), which should have the pertinent positives and negatives for all body systems. The ROS helps identify symptoms not stated in the HPI, which helps get a clear picture of the underlying disease.    

Objective Portion 

The objective part of the SOAP note does not have findings from the general assessment. This should include the patient’s general appearance, grooming, level of alertness, apparent state of health, comfort or distress, body language, and eye contact. As an abdominal assessment detailed findings from the abdomen assessment should be provided. This includes inspection findings like scars, abdomen symmetry, pigmentation, and movement with respiration (Rastogi et al., 2019). In addition, auscultation findings, including bowel sounds, vascular sounds, bruits, and friction rubs, should be included. Findings from the percussion of the abdomen, like the stomach, spleen, liver span, and kidney, should have been provided.  

Assessment Portion 

Enlarging aneurysms in AAA often cause flank, abdominal, or back pain. Abdominal palpation findings in AAA can include non-tender, pulsatile abdominal mass. Thus, the patient’s abdominal pain and tenderness support AAA. Clinical manifestations in a perforated ulcer include upper abdominal pain that can be localized to the left upper quadrant, right upper quadrant, or epigastrium (Tarasconi et al., 2020). Abdominal tenderness in the epigastric area supports perforated ulcer. Epigastric abdominal pain, tenderness, and guarding supports pancreatitis (Chatila et al., 2019).  

Appropriate Diagnostic Tests 

Appropriate diagnostic tests for this case include an abdominal ultrasound, complete blood count (CBC), and upper GI endoscopy. The CBC test will be necessary for assessing abdominal inflammation or infection through the WBC count. An abdominal ultrasound will be appropriate to determine the cause of the abdominal pain, including if there is an inflammation of the abdominal organs. In addition, an upper GI endoscopy will be used to detect inflammation and sores/ulcers in the upper GI tract.  

Would You Reject/Accept The Current Diagnosis? 

AAA does not qualify as a primary diagnosis since the patient does not have a non-tender, pulsatile abdominal mass, usually present in symptomatic patients. Besides, AA is usually symptomatic during a rupture, where patients present with constant pain and often get into frank shock (Hellawell et al., 2021). The patient has intermittent abdominal pain and has no signs of shock.  

Possible Conditions That May Be Considered As A Differential Diagnosis 

The possible differential diagnoses for this case are:  

Acute Pancreatitis: Acute pancreatitis manifests with upper abdominal pain that is usually constant and dull. It also presents with nausea, vomiting, tachycardia, fever, hypotension, diarrhea, abdominal distention, tenderness, and muscular guarding (Chatila et al., 2019). Therefore, Acute pancreatitis is a likely diagnosis owing to the clinical manifestations of vomiting, hypotension (BP-91/60), abdominal tenderness, and guarding.  

Acute Cholecystitis: Acute Cholecystitis is the inflammation of the gallbladder. Clinical manifestations include constant abdominal pain in the right upper quadrant, nausea, vomiting, fever, and elevated WBC and C-reactive protein (Mou et al., 2019). This differential is based on positive abdominal tenderness, vomiting, and guarding findings.  

Perforated ulcer: A perforated ulcer is a severe PUD complication. The classic triad of perforated peptic ulcer includes sudden onset of abdominal pain, abdominal rigidity, and tachycardia. Generally, abdominal pain never completely subsides despite premedical remedies (Tarasconi et al., 2020). Other clinical manifestations include nausea, severe dyspepsia, constipation, and fever. A perforated ulcer is a differential based on findings of abdominal pain that do not subside with PPIs, vomiting, and guarding,  

Conclusion 

The subjective portion of the SOAP note requires additional information on the characteristics of abdominal pain, aggravating and relieving factors, and severity of pain. It should also have the patient’s surgical history, immunization history, and ROS. The objective part should have included the general assessment and detailed abdominal assessment findings. The identified possible conditions include Acute pancreatitis, Acute cholecystitis, and Perforated Ulcer.  

 

References 

Chatila, A. T., Bilal, M., & Guturu, P. (2019). Evaluation and management of acute pancreatitis. World journal of clinical cases, 7(9), 1006–1020. https://doi.org/10.12998/wjcc.v7.i9.1006 

Hellawell, H. N., Mostafa, A. M., Kyriacou, H., Sumal, A. S., & Boyle, J. R. (2021). Abdominal aortic aneurysms part one: Epidemiology, presentation, and preoperative considerations. Journal of Perioperative Practice, 31(7-8), pp. 274–280. https://doi.org/10.1177/1750458920954014 

Mou, D., Tesfasilassie, T., Hirji, S., & Ashley, S. W. (2019). Advances in the management of acute cholecystitis. Annals of gastroenterological surgery, 3(3), 247–253. https://doi.org/10.1002/ags3.12240 

Rastogi, V., Singh, D., Tekiner, H., Ye, F., Mazza, J. J., & Yale, S. H. (2019). Abdominal Physical Signs of Inspection and Medical Eponyms. Clinical medicine & research, 17(3-4), 115–126. https://doi.org/10.3121/cmr.2019.1420 

Tarasconi, A., Coccolini, F., Biffl, W. L., Tomasoni, M., Ansaloni, L., Picetti, E., … & Catena, F. (2020). Perforated and bleeding peptic ulcer: WSES guidelines. World journal of emergency surgery, 15(1), 1-24. https://doi.org/10.1186/s13017-019-0283-9