Case Study: Assessing the Abdomen
Walden University Case Study: Assessing the Abdomen-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University Case Study: 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 Case Study: Assessing the Abdomen
Whether one passes or fails an academic assignment such as the Walden University Case Study: 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 Case Study: Assessing the Abdomen
The introduction for the Walden University Case Study: 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 Case Study: Assessing the Abdomen
After the introduction, move into the main part of the Case Study: 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 Case Study: 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 Case Study: 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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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.
Additional Objective Information
The nurse should obtain additional objective information from JR to make an informed diagnosis and develop a patient-centered care plan. Firstly, information about JR’s general appearance should be documented. This includes information such as his grooming, weight, alertness, and orientation. A comprehensive review of all the body systems should have also been done. For example, the assessment of the respiratory system is inadequate. Information such as the presence or absence of nasal flaring, wheezes, crackles, rhonchi, and peripheral or central cyanosis should have been documented (Katz et al., 2022). The assessment of the cardiovascular system should have extended to information such as the presence or absence of jugular venous distention or peripheral edema.
The information in the assessment of the gastrointestinal system is inadequate. Additional information such as the presence or absence of abdominal scars, organomegaly, pulsations, ascites, and visible blood vessels should have been documented. This is important because information such as palpable abdominal pulsations would indicate aortic abdominal aneurysm. Information about any abdominal pain on palpation and the location of the pain should have also been obtained and pain rating on a pain rating scale. The nurse should have also assessed the skin for capillary refill, turgor, cyanosis, and edema (Haque & Bhargava, 2022). Low capillary refill and poor skin turgor could indicate problems with circulation and hydration.
If Subjective and Objective Data Supports the Assessment
Subjective assessment data is the information a patient gives about their health problems. Subjective data supports JR’s assessment. Some of the subjective data include his chief complaints, history of the chief complaints, past medical history, medications, allergies, family, and social history. Objective data refers to the information that the healthcare provider obtains during assessment. Healthcare providers use methods such as inspection, palpation, percussion, and auscultation to obtain objective data (Malik et al., 2023). Objective data supports JR’s case study. Examples of objective data in the case study include vital signs and findings reported in the assessment of the heart, lungs, skin, and abdomen.
Appropriate Diagnostic Tests
Some diagnostic tests should be performed to develop JR’s accurate diagnosis. An occult stool test should be performed to determine if the client’s problem is due to an infection and rule out GI bleeding. A complete blood count test would also be performed to rule out an infection. Stool culture might also be performed to determine the accurate cause of JR’s problem. Antigen tests might also be performed to detect antigens associated with parasites and viruses that cause gastrointestinal problems such as gastroenteritis. A fecal fat test might be needed to rule out malabsorption problems in the client (Chen et al., 2021). Radiological investigations such as abdominal ultrasound and x-rays might be performed to rule out causes such as appendicitis and carcinoma.
Accepting or Rejecting the Current Diagnosis
I will accept the current diagnosis of left lower quadrant pain. The objective findings reveal the presence of left lower quadrant pain. This provisional diagnosis should guide the additional investigations performed to develop an accurate diagnosis. I also accept gastroenteritis as the other diagnosis for JR. Patients with gastroenteritis experience symptoms such as diarrhea, abdominal pain and cramping, nausea, vomiting, and loss of appetite (Chen et al., 2021). JR has these symptoms; hence, gastroenteritis is his other provisional diagnosis.
Three Possible Differential Diagnoses
Diverticulitis is the first differential diagnosis that should be considered for JR. Diverticulitis is an inflammation of the sigmoid colon that causes left lower quadrant pain. The pain worsens when a patient eats. The accompanying symptoms include diarrhea, constipation, bloating, nausea, and the passage of bloodstained stool (Sugi et al., 2020). Diagnostic investigations will rule in or out diverticulitis as the cause of JR’s problems.
The second differential diagnosis that should be considered for JR is peptic ulcer disease. Peptic ulcer disease is a condition that develops from the destruction of the stomach wall lining by pepsin or gastric acid secretion. It affects the distal duodenum, lower esophagus, or jejunum. Patients often experience epigastric pain 15-30 minutes after a meal. A diagnosis of duodenal ulcer disease is made if the patient reports epigastric pain 2-3 hours after a meal (Malik et al., 2023; Sverdén et al., 2019). The additional symptoms that patients with peptic ulcer disease experience include bloating, abdominal fullness, nausea and vomiting, hematemesis, melena, and changes in body weight.
Gastritis is the last differential diagnosis that should be considered for JR. Gastritis develops from the inflammation of the gastric mucosa. Factors such as infections, smoking, taking too much alcohol, prolonged use of aspirin and non-steroidal anti-inflammatory medications, and immune-mediated reactions might cause gastritis. Patients who are affected by gastritis experience a range of symptoms. They include stomach pain or upset, hiccups, belching, abdominal bleeding, nausea and vomiting, feeling of fullness, loss of appetite, and blood in stool or vomitus (Maret-Ouda et al., 2020; Rugge et al., 2020). Therefore, additional investigations should be performed to develop JR’s accurate diagnosis and treatment plan.
Conclusion
In summary, JR’s subjective and objective data is inadequate. Additional subjective and objective data should be obtained to guide the treatment plan. Subjective and objective data supports JR’s assessment. I accept the current diagnosis of left lower quadrant pain and gastroenteritis.. Different diagnostic investigations should be performed to rule in and out different differential diagnoses in the case study. The three differential diagnoses that should be considered for JR include gastritis, peptic ulcer disease, and diverticulitis.
References
Chen, P. H., Anderson, L., Zhang, K., & Weiss, G. A. (2021). Eosinophilic Gastritis/Gastroenteritis. Current Gastroenterology Reports, 23(8), 13. https://doi.org/10.1007/s11894-021-00809-2
Haque, K., & Bhargava, P. (2022). Abdominal Aortic Aneurysm. American Family Physician, 106(2), 165–172.
Katz, P. O., Dunbar, K. B., Schnoll-Sussman, F. H., Greer, K. B., Yadlapati, R., & Spechler, S. J. (2022). ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American Journal of Gastroenterology, 117(1), 27–56. https://doi.org/10.14309/ajg.0000000000001538
Malik, T. F., Gnanapandithan, K., & Singh, K. (2023). Peptic Ulcer Disease. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK534792/
Maret-Ouda, J., Markar, S. R., & Lagergren, J. (2020). Gastroesophageal Reflux Disease: A Review. JAMA, 324(24), 2536–2547. https://doi.org/10.1001/jama.2020.21360
Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An Update in 2020. Current Treatment Options in Gastroenterology, 18(3), 488–503. https://doi.org/10.1007/s11938-020-00298-8
Sugi, M. D., Sun, D. C., Menias, C. O., Prabhu, V., & Choi, H. H. (2020). Acute diverticulitis: Key features for guiding clinical management. European Journal of Radiology, 128, 109026. https://doi.org/10.1016/j.ejrad.2020.109026
Sverdén, E., Agréus, L., Dunn, J. M., & Lagergren, J. (2019). Peptic ulcer disease. BMJ, 367, l5495. https://doi.org/10.1136/bmj.l5495
In the accompanying SOAP note, the Caucasian female patient is 47 years old and has nausea, diarrhea, and widespread abdominal discomfort. The symptoms, according to the patient, began roughly three days ago. She also confirms a history of gastrointestinal bleeding that happened around four years ago but was successfully handled. The patient is now using diabetic and antihypertensive drugs to control his previous DM and HTN diagnoses. Denies using cigarettes but admits to consuming alcohol on occasion. A physical examination revealed that the patient’s discomfort originated in the left lower abdomen region. Hyperactive bowel noises are one of the physical symptoms. Based on these findings, the patient is diagnosed with gastroenteritis. The major purpose of this paper is to demonstrate an examination of the subjective and objective information presented and to arrive at the patient’s primary and differential diagnosis.
Subjective Data
The subjective information presented mostly highlights three basic symptoms shown by the patient: nausea, stomach discomfort, and diarrhea. Starting with abdominal discomfort, further information about its location and whether it has been growing worse or better is needed. The patient must also offer further details about the pain’s characteristics, such as throbbing or dull discomfort. Further information on nausea and diarrhea, including time and frequency, is also required for a thorough examination of the patient. The patient also reports diarrhea but fails to offer more information on the characteristics of her stool and bowel movement, which is critical for ruling out differentials (Stuempfig & Seroy, 2020). Additional information on the frequency, dose, and duration of usage of the individual medicines indicated is needed concerning the patient’s current medication. The information will aid in the promotion of good prescribing practices and the avoidance of hazardous medication responses. Other pertinent variables lacking from the offered subjective data are health promotion strategies such as food habits and physical exercise.
Objective Data
The objective data is extremely exact, however, there is insufficient information to further evaluate the patient’s principal complaint. A thorough physical examination from head to toe is essential for adult patients with comorbidities to determine that no other underlying ailment is contributing to the current symptoms. During a physical examination, the doctor discovered that the patient’s pain was coming from the left lower abdomen quadrant and was accompanied by hyperactive bowel noises. Building on these results, a thorough examination of the patient’s abdomen is required to look for bulges, hernias, swollen veins, or tumors (Pesek et al., 2019). Visual examinations are also required to determine whether the patient’s history of GI bleeding has been entirely resolved. Visual examinations are also required to determine whether the patient’s history of GI bleeding has been entirely resolved. The objective data also lack nutritional evaluation findings, which are critical in ruling out dietary reasons for the patient’s symptoms, such as food poisoning.
Assessment
The patient evaluation presented implies a diagnosis of gastroenteritis. The subjective and objective data both support the judgment, but not conclusively. Gastroenteritis is defined by GI disturbances such as diarrhea, stomach discomfort and nausea, and vomiting, all of which the patient experiences (Axelrad et al., 2019). Some important diagnostic characteristics, such as dysuria and infection symptoms, are lacking. As a result, the objective data show left lower quadrant stomach discomfort and hyperactive bowel noises, which are also seen in gastroenteritis patients. To confirm this diagnosis, however, stool investigation was required for culture and sensitivity tests to identify the causative infectious organisms.
Appropriate Diagnostic Tests
Patients who appear with GI symptoms such as diarrhea, stomach discomfort, and nausea, which are frequent in a variety of GI illnesses, require a thorough examination of the abdomen area to ensure an appropriate diagnosis. To begin, blood tests such as a complete blood count are required to rule out infections. For the adult patient in the case study, a rapid stool test was required to identify the causal pathogen, such as rotavirus or any other bacterium that might cause gastroenteritis (Osterwalder et al., 2020). Metabolic panel tests are also required to establish if the patient’s diabetes was adequately treated and how the patient’s obesity may be managed. CT scans and X-rays of the entire abdomen area are also required to rule out any deformities or abnormalities that may be causing the patient’s symptoms. Additional tests, such as PCR, are required for the diagnosis of calicivirus infection in the feces.
Current Diagnosis
The patient in the case study was diagnosed with gastroenteritis. The lab data does not fully support this diagnosis since information indicating the causal bacterium is absent. Only the results of the stool test can confirm the diagnosis, thus it cannot be accepted at this time (Sharifi et al., 2022). As a result, the patient tested negative for infection-related symptoms such as fever and chills, which are critical in identifying individuals with gastroenteritis. As a result, the patient reported a history of GI bleeding, which is significant in determining the source of the patient’s current symptoms. As a result, additional investigation of the source of the patient’s GI bleeding and whether it is related to the current symptoms was required to rule out other probable causes such as intestinal obstruction, irritable bowel syndrome (IBS), and inflammatory bowel disease.
Differential Diagnosis
Inflammatory bowel disease (IBD), Irritable bowel syndrome (IBS), and intestinal obstruction (IO) are the 3 major differential diagnoses. Inflammatory bowel disease (IBD) is a broad term encompassing conditions characterized by persistent inflammation of the gastrointestinal system (Axelrad et al., 2019). The two most common kinds of IBD are ulcerative colitis and Crohn’s disease. This disease is characterized by decreased appetite, bloody stool, bloody urine, lethargy, stomach discomfort, and diarrhea. The patient has stomach discomfort and diarrhea. However, a stool test is required to confirm this diagnosis.
Irritable bowel syndrome (IBS) is a common gastrointestinal illness that affects the large intestine. Patients with IBS will experience gastrointestinal discomfort, diarrhea, cramps, bloating, and constipation (Sharifi et al., 2022). Because the patient has most of these symptoms, IBS is a plausible diagnosis. Upper endoscopy and colonoscopy, however, are required to confirm this diagnosis.
Finally, intestinal obstruction (IO) is defined as a considerable physical impediment of the intestinal tract caused by a pathological disease that results in bowel obstruction (Osterwalder et al., 2020). Cramping, stomach discomfort, a lack of flatus, and constipation are all symptoms of this condition. An X-ray of the colon, however, is required to confirm this diagnosis.
References
Axelrad, J. E., Olén, O., Askling, J., Lebwohl, B., Khalili, H., Sachs, M. C., & Ludvigsson, J. F. (2019). Gastrointestinal Infection Increases Odds of Inflammatory Bowel Disease in a Nationwide Case–Control Study. Clinical Gastroenterology and Hepatology, 17(7), 1311-1322.e7. https://doi.org/10.1016/j.cgh.2018.09.034
Osterwalder, I., Özkan, M., Malinovska, A., Nickel, C. H., & Bingisser, R. (2020). Acute Abdominal Pain: Missed Diagnoses, Extra-Abdominal Conditions, and Outcomes. Journal of Clinical Medicine, 9(4), 899. https://doi.org/10.3390/jcm9040899
Pesek, R. D., Reed, C. C., Muir, A. B., Fulkerson, P. C., Menard-Katcher, C., Falk, G. W., Kuhl, J., Martin, E. K., Magier, A. Z., Ahmed, F., Demarshall, M., Gupta, A., Gross, J., Ashorobi, T., Carpenter, C. L., Krischer, J. P., Gonsalves, N., Spergel, J. M., Gupta, S. K., & Furuta, G. T. (2019). Increasing Rates of Diagnosis, Substantial Co-Occurrence, and Variable Treatment Patterns of Eosinophilic Gastritis, Gastroenteritis, and Colitis Based on 10-Year Data Across a Multicenter Consortium. The American Journal of Gastroenterology, 114(6), 984–994. https://doi.org/10.14309/ajg.0000000000000228
Sharifi, M., Safarpour, A. R., Barati-Boldaji, R., Rahmati, L., Karimi, S., & Bagheri Lankaran, K. (2022). Post-Infectious Irritable Bowel Syndrome after an Epidemic of Gastroenteritis in South of Iran. Middle East Journal of Digestive Diseases, 14(3), 304–309. https://doi.org/10.34172/mejdd.2022.287
Stuempfig, N. D., & Seroy, J. (2020). Viral Gastroenteritis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK518995/
| Excellent | Good | Fair | Poor | ||
| Main Posting | 45 (45%) – 50 (50%)
Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.
Supported by at least three current, credible sources.
Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
40 (40%) – 44 (44%)
Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.
At least 75% of post has exceptional depth and breadth.
Supported by at least three credible sources.
Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
35 (35%) – 39 (39%)
Responds to some of the discussion question(s).
One or two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with two credible sources.
Written somewhat concisely; may contain more than two spelling or grammatical errors.
Contains some APA formatting errors. |
0 (0%) – 34 (34%)
Does not respond to the discussion question(s) adequately.
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only one or no credible sources.
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style. |
|
| Main Post: Timeliness | 10 (10%) – 10 (10%)
Posts main post by day 3. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not post by day 3. |
|
| First Response | 17 (17%) – 18 (18%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
15 (15%) – 16 (16%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
13 (13%) – 14 (14%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 12 (12%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Second Response | 16 (16%) – 17 (17%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
14 (14%) – 15 (15%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
12 (12%) – 13 (13%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 11 (11%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Participation | 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days. |
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| Total Points: 100 | |||||