Feb 23, 2024 LAB ASSIGNMENT: ASSESSING THE ABDOMEN
LAB ASSIGNMENT: ASSESSING THE ABDOMEN
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.
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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
Abdominal Assessment
Abdominal problems have adverse effects on the health and wellbeing of the patients. Nurses are expected to utilize their knowledge and skills in comprehensive history taking and patient assessment to develop accurate diagnoses and treatment plans for their patients. Therefore, this paper is an examination of J.R’s case study. J.R is a 47-year-old client that has come to the hospital with generalized abdominal pain for the last three days and nausea. The purpose of this paper is to examine the additional subjective and objective information to be obtained from the client, whether the case study has subjective and objective data, diagnostic investigations, and decision related to the developed diagnosis.
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Analysis of Subjective Portion
Subjective data relates to that obtained from the patient. It focuses on the experiences of the patient with the health problem. Additional subjective information should be obtained from the patient to come up with an accurate diagnosis and treatment plan. One of the subjective data that should be obtained from the client is quantification of the abdominal pain. Information about the pain rating, severity, character, and relieving, precipitating, and aggravating factors should be obtained. The other aspect of the pain should focus on whether the pain is generalized, radiating to other body parts, or increasing or decreasing in intensity. The pain should also be described in terms of whether it is sudden or gradual.
Moreover, the nature of diarrhea that the client reports should also be quantified. A focus should be placed on aspects such as the frequency of the diarrhea in a given period to determine if they client is dehydrated or not. The additional information about diarrhea include color of stool, relieving, aggravating, and precipitating factors. The provider should also obtain information about the dietary history of the client. Food poisoning could be a factor to consider in this client’s case. As a result, information about recent dietary habits and perceived hygiene of the foods should be obtained to determine the cause of the problem.
The hygiene status and source of water that the client drinks should be obtained to ascertain whether the problem is a water-borne disease. Since the client has history of gastrointestinal bleeding, it would be necessary to ask about recent changes in color, smell, and texture of the stool prior to the current problems (Jarvis & Eckhardt, 2019). Such information will aid in ruling out causes such as ulcers of the gastrointestinal system.
Analysis of Objective Position
Healthcare providers obtain objective data using methods such as observation, palpation,
LAB ASSIGNMENT ASSESSING THE ABDOMEN
percussion, and auscultation. The data is important in confirming or validating the subjective data given by the patient. Additional objective data should be obtained from the client. They include the general appearance of the client during the first encounter with the healthcare provider. The healthcare provider should provide a description of the grooming, energy levels, body weight, and if the patient is dehydrated or not. The provider should have also assessed the patient for hydration status and jaundice by checking on skin turgor and sclera for jaundice. The patient should have also provided comprehensive abdominal assessment to determine whether there is distention, bowel movements, organomegally, distention of veins, and scars. The provider should have also palpated the abdomen for tenderness, rigidity, or any rebound tenderness. The information could have helped rule out causes such as bowel obstruction and organomegally (Jarvis, 2019). The objective data could have facilitated the development of an accurate diagnosis for the client.
Analysis of the Assessment
Objective and subjective data support the assessment of JR. Examples of subjective data that supports the assessment include information about diarrhea, nausea, stomach pains, past medical, medication, allergies, family, and social histories. Examples of objective data include the vitals and heart, lungs, skin, and abdominal findings.
Diagnostic Tests
Stool test is the most appropriate diagnostic investigation for JR. Stool analysis should be performed to determine if the client has an infection or the cause could be due to gastrointestinal bleeding. Blood tests such as complete blood count are also recommended to determine if the client has low hemoglobin level due to bleeding or elevated white blood cell count to indicate infection. Since the client has a history of gastrointestinal bleeding, it would be appropriate to perform abdominal ultrasound to determine the actual cause of the problem (Jarvis & Eckhardt, 2019).
Rejecting/Accepting the Diagnosis
I would accept the current diagnosis. Patients with gastroenteritis experience symptoms similar to those of JR. The symptoms include abdominal cramps, vomiting, nausea, and diarrhea. The infection is short-term, implying symptom resolution over time. JR reports that the pain severity has declined, implying a potential symptom resolution in gastroenteritis. He also complains of diarrhea, abdominal pain, and nausea, hence, the decision to accept the diagnosis (Bányai et al., 2018). The differential diagnoses to be considered include abdominal obstruction, colon cancer, and inflammatory bowel disease. The above differentials have patients experiencing either nausea, vomiting, diarrhea, or abdominal pains. However, it may not be abdominal obstruction due to the presence of diarrhea and absence of abdominal distention. Diagnostic investigations such as abdominal ultrasound are needed to rule out colon cancer. The patient does not have any predisposition to environmental triggers, hence, ruling out inflammatory bowel disease (Guan, 2019).
Conclusion
Subjective and objective data guide the diagnoses developed for health problems affecting patients. JR is likely to be suffering from gastroenteritis. Additional subjective and objective data is however needed to develop an accurate diagnosis. Diagnostic investigations should be used to develop accurate diagnosis for the patient.
After analysis of the objective, subjective and likely diagnostics acute pancreatitis is the likely diagnosis. The majority of the clinical manifestations the patient presented with were similar to it and the objective data collected also contributed to this being a possible diagnosis. The recommended diagnostics would have further proved this as they would have shown the abnormality in the pancreas and thus diagnosing the patient appropriately. The initial information gathered regarding the patient was relevant though additional information in the objective and subjective portions were required in order to properly diagnose the patent and enable there to be proper measures to help the patient (Dains & Scheibel, 2019).
References
Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/S0140-6736(18)31128-0
Guan, Q. (2019). A Comprehensive Review and Update on the Pathogenesis of Inflammatory Bowel Disease. Journal of Immunology Research, 2019, e7247238. https://doi.org/10.1155/2019/7247238
Jarvis, C. (2019). Physical Examination & Health Assessment Access Code. Elsevier Health Sciences.
Jarvis, C., & Eckhardt, A. (2019). Physical Examination and Health Assessment. Elsevier.
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
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 report
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