Assessing the Abdomen Sample Essay

Posted: November 1st, 2022

Assessing the Abdomen Sample Essay

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT 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 assignment, you will analyze a SOAP 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. Assessing the Abdomen Sample Essay . 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, hyperctive bowel sounds, pos pain in the LLQ Diagnostics: None ASSESSMENT: Left lower quadrant pain Gastroenteritis PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. To prepare: With regard to the SOAP note case study provided: Review this week’s Learning Resources, and consider the insights they provide about the case study. 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. To complete: Analyze the subjective portion of the note. List additional information that should be included in the documentation. Analyze the objective portion of the note.Assessing the Abdomen Sample Essay . 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/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 3 different references from current evidence based literature. Week 6: Assessment of 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 Assesment 1: Assessing the Abdomen In this assignment, you will analyze a SOAP 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. NURS-6512N-17,Advanced Health Assessment.2018 Winter Qtr 11/26-02/17-PT27 COURSE HOME SYLLABUS COURSE CALENDAR COURSE OVERVIEW COURSE INFORMATION RESOURCE LIST CLASS CAFÉ CONTACT THE INSTRUCTOR MY GRADES DOC SHARING WEBLIOGRAPHY KALTURA MEDIA UPLOADER WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 WEEK 9 WEEK 10 WEEK 11 DISCUSSIONS EXAMS ASSIGNMENTS SAFEASSIGN DRAFTS TOOLS STUDENT SUPPORT WALDEN LINKS GUIDELINES AND POLICIES View options Course Institution Announcements Week 6 Overview Posted on: Sunday, December 30, 2018 11:59:00 PM EST Week 6: Assessment of 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 Assesment 1: Assessing the Abdomen In this assignment, you will analyze a SOAP 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. NURS-6512N-17,Advanced Health Assessment.2018 Winter Qtr 11/26-02/17-PT27 COURSE HOME SYLLABUS COURSE CALENDAR COURSE OVERVIEW COURSE INFORMATION RESOURCE LIST CLASS CAFÉ CONTACT THE INSTRUCTOR MY GRADES DOC SHARING WEBLIOGRAPHY KALTURA MEDIA UPLOADER WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 WEEK 9 WEEK 10 WEEK 11 DISCUSSIONS EXAMS ASSIGNMENTS SAFEASSIGN DRAFTS TOOLS STUDENT SUPPORT WALDEN LINKS GUIDELINES AND POLICIES View options Course Institution Announcements Week 6 Overview Posted on: Sunday, December 30, 2018 11:59:00 PM EST Week 6: Assessment of 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 Assesment 1: Assessing the Abdomen In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. Assessing the Abdomen Sample Essay . 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. Learning objectives students will: Evaluate abnormal abdomen and gastrointestinal findings. Apply concepts, theories and principles relating to health In this assignment you will analyze a SOAP note case study that describe 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 formulate a differential diagnosis with several possible conditions

Additional Information to Be Included In Subjective Documentation

The nature of the onset of the abdominal pain should be established in terms of its onset, origin, radiation, relieving, aggravating factors and any past abdominal issues. In patients with gastroenteritis, abdominal pain is often of sudden onset since it usually starts as an acute infectious illness (Lacy et al., 2016). Since the client also complained of diarrhea, its onset should also be stated, color, approximate number of diarrhea episodes in a day and whether it is bloody, watery or mucoid. Gastroenteritis can be caused by a virus, bacteria or parasitic infection. Bacterial gastroenteritis often results in bloody diarrhea while viral gastroenteritis leads to watery diarrhea (Scallan et al., 2018). Therefore, the nature of the stool would help to provide a more specific diagnosis hence a more specific management approach. The relieving or aggravating factors of the client’s diarrhea should also be documented. Assessing the Abdomen Sample Essay

The client’s tolerance for both solid and liquid foods should be made known, including how she obtains her foods/groceries and method of preparation. Gastroenteritis is known to result from consuming contaminated water or food which might also be prepared without adequately following sanitation protocols (Kendall & Moreira, 2017). The client’s recent travel history should also be documented since gastroenteritis tends to commonly develop when traveling, following exposure to infectious agents. The presence of any previous abdominal diagnoses such as cholecystitis or diverticulitis should be established. The client should be asked other associated symptoms such as bloating, burning, vomiting or difficulty in swallowing.

Additional Information to Be Included In Objective Documentation

Additional objective data to include inpatient documentation is the characteristic of the stool and possible exposure to infectious diseases. The patient could also have recently undergone stressful life events that negatively influenced her health status. The appearance of the abdomen in terms of its contours symmetry and skin color on inspection should be included. On palpation, it should be recorded whether or not there are any masses present, scars, veins, striae, pigmentation and pulsations (Kendall & Moreira, 2017). On Auscultation with the diaphragm of a stethoscope, it should be recorded whether or not bowel sounds are present in terms of its character, bowel sounds frequency, the presence of bruits in the iliac, aortic, renal and femoral places. Bruits signify gastroenteritis, obstruction or peritonitis (Kendall & Moreira, 2017).  On percussion, presence or absence of abnormal findings such as enlarged organs, possible distention, ascites, and palpable masses should be documented. The findings on deep and superficial palpation such as areas of tenderness or rebound tenderness should also be documented. In case a mass is felt, its location, shape, size, pulsation, firmness, and mobility should be documented. Assessing the Abdomen Sample Essay

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            Normally, an abdominal examination should reveal a soft, symmetric and round abdomen with no distension, scars, lesions or visible peristalsis. Besides, the aorta should be midline with no bruits and visible pulsations. The umbilicus ought to be midline and inverted with no herniation. On auscultation, bowel sounds should be present in all 4 quadrants, the kidney, spleen, and liver should not be palpable with no tenderness on palpation (Lacy et al., 2016).

Whether the Assessment Is Supported By Subjective and Objective Information

The client’s assessment revealed that he had left lower quadrant pain and gastroenteritis. Based on the subjective information, the client reported symptoms of diarrhea and severe abdominal pain for 3 days. Essentially, these are some of the symptoms of gastroenteritis which often begin between 12-72 hours after contact with an infectious agent. Objective information reveals that the client had temperatures of 99.8 which revealed a low-grade fever. Fever is a possible occurrence in patients with gastroenteritis and may be accompanied with symptoms of dehydration and lack of energy which are both as a result of persistent vomiting and diarrhea (Lausch et al., 2017).  It is also clear that the client’s objective data revealed hyperactive bowel sounds. In patients with gastroenteritis, bowel sounds are likely to increase due to diarrhea/frequent bowel movements.Assessing the Abdomen Sample Essay

Appropriate Diagnostic Tests For This Case and How the Results Would Be Used to Make a Diagnosis

In this case, a potential diagnostic test would be the client’s medical history and a stool test. Based on the client’s medical history, potential signs and symptoms of gastroenteritis that she had experienced will be compared against the actual signs and symptoms of gastroenteritis to make a definite diagnosis (Bartsch, et al., 2016).  Similarly, a stool test would be used to ascertain whether or not the infection is viral, bacterial or parasitic. Should the stool be blood, there would be a high likelihood that the diagnosis would be bacterial gastroenteritis. Should it be watery, it will be viral gastroenteritis (Lausch et al., 2017).

Whether I Would Accept/Reject the Current Diagnosis with Reasons

The client has currently been diagnosed with gastroenteritis which is basically an inflammation of the gastrointestinal tract. The symptoms of gastroenteritis are abdominal pain, fever, diarrhea, vomiting, and dehydration which start 12-72 hours upon contact with an infectious agent and lasts for less than two weeks (Lausch et al., 2017).   Abdominal pain often results from frequent episodes of diarrhea and hence the hyperactive bowel sounds. These findings are similar to the client’s presentation, subjective and objective data. Therefore, I would accept the current diagnosis.

Possible Differential Diagnoses

Appendicitis

Inflammatory Bowel Disease

Urinary Tract Infection

References

Bartsch, S. M., Lopman, B. A., Ozawa, S., Hall, A. J., & Lee, B. Y. (2016). Global economic burden of norovirus gastroenteritis. PloS one, 11(4), e0151219.

Kendall, J. L., & Moreira, M. E. (2017). Evaluation of the adult with abdominal pain in the emergency department. UpToDate.(level 5).

Lacy, B. E., Mearin, F., Chang, L., Chey, W. D., Lembo, A. J., Simren, M., & Spiller, R. (2016). Bowel disorders. Gastroenterology, 150(6), 1393-1407.

Lausch, K. R., Westh, L., Kristensen, L. H., Lindberg, J., Tarp, B., & Larsen, C. S. (2017). Rotavirus is frequent among adults hospitalized for acute gastroenteritis. Dan Med J, 64(1), A5312.

Scallan, E., Griffin, P. M., McLean, H. Q., & Mahon, B. E. (2018). Hospitalizations due to bacterial gastroenteritis: A comparison of surveillance and hospital discharge data. Epidemiology & Infection, 146(8), 954-960. Assessing the Abdomen Sample Essay