Feb 23, 2024 NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay
NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay
NURS 6512 Week 6 Assignment 1 Lab Assignment Assessing the Abdomen Sample Essay
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
Abdominal Assessment
Nurses and other healthcare providers play an important role in the promotion of health of diverse patient populations. They utilize their knowledge and skills in patient assessment to determine the actual and potential health needs of their patients. Abdominal health problems are part of the conditions that nurses address in their daily practice. Therefore, this essay examines a case study of a patient that came with abdominal health problem. The patient is a 47-year-old male that complained of generalized abdominal pain, which started 3 days ago. The essay examines the additional subjective and objective data that should be obtained from the patient, diagnostic investigations, and differential diagnoses that should be considered.
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Subjective Analysis
Subjective information refers mainly to the data that healthcare providers obtain concerning the experiences of the patients with a health problem. Subjective data explores a wide range of aspects of a disease such as the concerns and feelings of the patient. A number of subjective information should be obtained from JR. One of them is the character of the abdominal pain. Besides the rating and intensity of the abdominal pain, questions related to aggravating, precipitating and relieving factors should be obtained. There is also a need to obtain information on whether the pain radiates to other parts of the body, generalized, increasing or decreasing in severity or not.
Information about the pain such as its character such as being gradual or of sudden onset should also be obtained. Additional information about the diarrhea should also be obtained. For example, the frequency and number of diarrhea experienced in a day should be obtained. This is important as it provides clues into the hydration status of the patient. Information about the aggravating, precipitating, and relieving factors for diarrhea should also be obtained (Perry et al., 2021). Recent dietary history and habits should also be explored to determine the potential cause of the health problem. The history obtained from the JR indicates that he has a history of GI bleeding. It is therefore important to ask information related to whether there is blood stained stool, smell and color to determine the exact cause of the problem. Comprehensive acquisition of subjective information is therefore crucial to guide the development of the most accurate diagnosis for JR.
Objective Analysis for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen
Objective data refers to the information that the healthcare provider obtains through physical
NURS 6512 Week 6 Assignment 1 Lab Assignment Assessing the Abdomen Sample Essay
examination. It entails the use of techniques such as observation, auscultation, percussion, and palpation. Objective data is mainly used to validate subjective data and develop accurate diagnosis of a problem affecting a client. A number of objective data needs to be obtained from the client in the case study. The first aspect of objective data is documenting the general appearance of JR. Information about the general appearance of the patient such as if well dressed and sick looking should have been obtained. Patients with chronic illnesses such as colon cancer may appear lethargic and malnourished.
JR should have also been examined for jaundice and hydration status. Inspection of the abdomen should also be done to determine whether there is abdominal distention. Abdominal distention may lead to the development of diagnoses such as organomegally or pancreatic cancer. Observation should also aim at determining if there are any scars and distended veins. Palpation should also be done to determine if there is abdominal rigidity, tenderness, or rebound tenderness. Rigidity could indicate accumulation of fluid or abdominal matter in the peritoneal cavity, hence bowel obstruction (Cox, 2019). Therefore, the above objective data would guide the development of accurate diagnosis for the client.
If the Assessment is supported by Subjective and Objective Information
The assessment in the case study is supported by objective and subjective information. As noted initially, subjective data focuses on the perceptions and feelings of the patient with a disease. JR reported subjective data such as diarrhea and vomiting. He also reported pain and history of GI bleeding. Objective data focuses on the information that the healthcare provider obtains through physical assessment (Estes et al., 2019). The data such as vital signs, absence of murmurs, and intact skin without lesions are some of the objective information in the case study.
Diagnostic Tests for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen
Additional diagnostic tests should be performed to come up with an accurate diagnosis of the health problem that the client in the case study is experiencing. One of the tests would be stool occult test to determine if there is blood in the stool or not. The other test is complete blood count to determine if the client has infection. Liver function tests may also be performed to determine whether there is an abnormality with liver enzymes, which indicate liver disease. Ultrasound of the abdomen may also be needed to view the abdominal organs for any abnormality (Williams, 2021).
Accepting or Rejecting Diagnosis and Possible Conditions
I would reject the diagnosis for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen. The assessment was not comprehensive. For example, it did not examine the lower quadrant pain to determine its character. The subjective data points towards a possible diagnosis of gastroenteritis. The presence of abdominal pain, low-grade fever, vomiting and nausea are often associated with gastroenteritis. One of the differential diagnoses for JR in this case study is abdominal obstruction. Patients with abdominal obstruction often experience symptoms such as abdominal pains, vomiting, nausea, and vomiting.
However, this condition is least likely due to the presence of diarrhea (Perry et al., 2021). The other possible differential diagnosis is pancreatic cancer. Patients with pancreatic cancer may experience symptoms such as abdominal pains, nausea, and vomiting. However, this should be ruled out by performing comprehensive history taking and physical examination. Diagnostic investigations such as abdominal ultrasound will help determine if JR is suffering from pancreatic cancer. The last differential diagnosis is diverticulitis. Diverticulitis is also associated with left lower quadrant pain, nausea, fever, and vomiting (Williams, 2021). The condition should be ruled out through a CT scan of the abdomen.
Conclusion
In conclusion of NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen, comprehensive assessment and physical examination is important in patient care. Additional subjective and objective data should be obtained from the patient in the case study to develop an accurate diagnosis. In addition, diagnostic investigations should be done to determine the actual cause of the abdominal problem. Differential diagnoses should be considered to guide the development of the treatment plan.
References
Cox, C. L. (2019). Physical Assessment for Nurses and Healthcare Professionals. John Wiley & Sons.
Estes, M. E. Z., Calleja, P., Theobald, K., & Harvey, T. (2019). Health Assessment and Physical Examination. Cengage AU.
Perry, A. G., Potter, P. A., Ostendorf, W., & Laplante, N. (2021). Clinical Nursing Skills and Techniques—E-Book. Elsevier Health Sciences.
Williams, P. A. (2021). Fundamental Concepts and Skills for Nursing—E-Book. Elsevier Health Sciences.
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
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