Abdominal Assessment Essay Assignment

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Abdominal Assessment Essay Assignment

Abdominal Assessment

Subjective portion and additional information to be included in the documentation.

In this case study the subjective data entails the feelings of the patient regarding generalized abdominal pain. Using a scale of 0-10, the clinician should enquire about the intensity of the pain along with whether it is localized or migratory (Jarvis,2018). In addition to the information about quantity of the pain, extra information on whether the pain was sudden or gradual should be included. Other important additional information that should be included in the documentation include what the patient was doing during the onset of pain, any changes in the appetite and dietary habits, the character, exacerbating, and relieving factors of the pain (Jarvis,2018). Abdominal Assessment Essay Assignment. c onsidering the patient states to have not taken any medications. It would also be important to include information about the last physical examination of the patient including the diagnostic test performed if any and the findings of the diagnostic studies. All this information is essential in having a better understanding of the patient’s condition.

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Objective portion and additional information to be included in the documentation.

Since the chief complain of the patient is generalized abdominal pain, there is a need to have a more thorough abdominal assessment. Information such as abdominal musculature observation, abdomen coloring, abdominal distention observation along with abdomen percussion should be documented after the abdominal examination (Jarvis,2018). The clinician should also ensure that findings are more detailed for accurate diagnosis. Apart from the hyperactive bowel sounds, other additional information including findings of the palpated sites such as the liver, assessment of abdominal reflexes, observations on rebound tenderness and performance of murphy’s signs should be included (Jarvis, 2018). All this information is critical to determine the causes that are similar to the symptoms of the patient which should guide on the diagnostics to be involved.

Assessment support by the subjective and objective information

The case assessment signifies lower quadrant pain presence along with gastroenteritis. This assessment is supported by subjective data where the symptoms of diarrhoea in the absence of vomiting and low-grade fever are reported by the patient forming the characteristic findings to support gastroenteritis findings. However, the objective data is deficient and pends further evaluation. Abdominal Assessment Essay Assignment

 

Most appropriate diagnostic tests and use of the results to make a diagnosis

 

For patients with recurring abdominal pain similar to this case, the following diagnostic tests should be done:

  1. Complete Blood Count that will help identifying an infection or inflammatory response indicated by elevated WBC. In addition, this test will help to reveal thrombocytosis along with normochromic anemia which are the key findings for pancreatic cancer patients.
  2. Liver function test to determine if there is presence of obstructive jaundice indicated by high bilirum and serum amylase levels. Abdominal Assessment Essay Assignment.
  • Erythrocyte Sedimentation Rate to determine the presence of tissue injury or inflammation indicated by an increased value of the Sedimentation Rate
  1. Urinalysis for a kidney infection, kidney stones, renal failure and systemic disease evaluation
  2. Fecal occult blood test that will assist in ruling out gastrointestinal (GI) bleeding.
  3. Kidney, ureter, and bladder (KUB that will help to exclude free air or perforation and obstruction, or intestinal obstruction confirmation.
  • Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) to ascertain suspected retroperitoneal bleeding, pancreatitis, pelvic abscess, hernia, diverticular disease or obstruction (Gore et al,2015).

Accepting or rejecting the current diagnosis

 

The current diagnosis of gastroenteritis is acceptable although further assessment and testing is required to ascertain the diagnosis. Though the diagnosis of gastroenteritis can be achieved through use of subjective and objective data only, it is recommended that any the possible diagnosis is ruled out. Normally the common symptoms of gastroenteritis include diffuse abdominal pain that is crampy and is usually accompanied by diarrhoea, nausea, vomiting and fever (Reed, Woosley & Dellon ,2015). The patient in this case study reports to have low grade fever with nausea and diarrhoea without vomiting. Besides the patient has hyperactive bowel sounds a symptom that patients with gastroenteritis have.

 

Differential Diagnosis

The patient could be having various abdominal issues.  The patient complains of diffuse abdominal pain accompanied with nausea and has hyperactive bowel sounds.  Abdominal Assessment Essay Assignment. These symptoms can also point to, bowel obstruction, diverticulitis, or irritable bowel syndrome (IBS).  Every condition needs particular diagnostic testing to have an accurate diagnosis.

  • Bowel obstruction is common among the newborns, the elderly, and people with recent GI surgery. The causes of intestinal obstruction are abdomen adhesions forming after surgery, inflamed intestine, hernias, and colon cancer (Gore et al,2015). The common symptoms include crampy pain with sudden onset, vomiting, severe constipation as well as Hyperactive, high-pitched bowel sounds present with a small bowel obstruction (Gore et al,2015). In lower obstruction a mass may be palpable as well as presence of abdominal distention. abdominal x-rays, CT scan, or MRI helps in making definitive diagnosis (Gore et al,2015).
  • Diverticulitis is the most common cause of pain in the left lower quadrant (Young-Fadok,2018). It involves an inflammation and infection of diverticula present in the large intestine.  The major signs and symptoms of Diverticulitis involve nausea, vomiting, constipation, diarrhea, excessive gas and fever (Young-Fadok,2018). Abdominal CT scan is the recommended best imaging study to confirm the condition.
  • Irritable bowel syndrome (IBS is a common condition with clinical presentation involving abdominal cramping, pain, bloating, diarrhea and constipation (Chey, Kurlander & Eswaran, 2015). Patients with this disorder have a normal bowel examination without presence of blood in the stool. In cases where the onset of IBS is at middle age, the blood is present in the stool, there is presence of colorectal cancer family history or the patient show no improvement after 6 to weeks of therapy barium enema (BE) should be the next examination to consider constipation (Chey, Kurlander & Eswaran, 2015).

 

References

Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: a clinical review. Jama, 313(9), 949-958.

Gore, R. M., Silvers, R. I., Thakrar, K. H., Wenzke, D. R., Mehta, U. K., Newmark, G. M., & Berlin, J. W. (2015). Bowel obstruction. Radiologic Clinics, 53(6), 1225-1240.

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.

Reed, C., Woosley, J. T., & Dellon, E. S. (2015). Clinical characteristics, treatment outcomes, and resource utilization in children and adults with eosinophilic gastroenteritis. Digestive and Liver Disease, 47(3), 197-201.

Young-Fadok, T. M. (2018). Diverticulitis. New England Journal of Medicine, 379(17), 1635-1642. Abdominal Assessment Essay Assignment.

CASE STUDY

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. 

CASE STUDY 

ABDOMINAL ASSESSMENT

Subjective:

  • CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
  • HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
  • PMH: HTN, Diabetes, hx of GI bleed 4 years ago
  • Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
  • Allergies: NKDA
  • FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
  • Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

  • VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Skin: Intact without lesions, no urticaria
  • Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
  • Diagnostics: None

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Assessment:

  • Left lower quadrant pain
  • Gastroenteritis

To Prepare

Review the Episodic note case study.

  • With regard to the Episodic note case study provided:

 

    • Consider what history would be necessary to collect from the patient in the case study.
    • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
    • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Abdominal Assessment Essay Assignment.

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.

With regard to the SOAP note case study provided, address the following:

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

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

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

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

  • Would you reject or accept the current diagnosis? Why or why not?
    ·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.—

Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.—

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation—

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.—  Abdominal Assessment Essay Assignment.