Feb 23, 2024 NURS 6512 Assessing the Abdomen
NURS 6512 Assessing the Abdomen
NURS 6512 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.
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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
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,
NURS 6512 Assessing the Abdomen
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.
The assessment is supported by the objective and subjective information. This is observed the patient had stated a history of pain in the stomach. The pain then became worse. The patient sough medical intervention from a hospital though there was no relief. The pain increased in severity until he vomited. Then the patient went to the hospital again until it was identified the patient is experiencing pain in the epigastric region consistent with occurrence of abdominal pain. This all supports the chief complaint. The listed differentials are also relevant as they are conditions affecting the abdominal region hence are in line with what is affecting the patient (Dains & Scheibel, 2019).
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.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
• Please save your Assignment using the naming convention “WK6Assgn1+last name+first initial.(extension)” as the name.
• Click the Week 6 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 6 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK6Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 6 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 6 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 7 of Week 6
To participate in this Assignment:
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
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