Posted: November 11th, 2022
Assessment 1: Assessing the Abdomen Essay
Assesment 1: Assessing the Abdomen 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. 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. Assessment 1: Assessing the Abdomen Essay. 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. 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. Assessment 1: Assessing the Abdomen Essay
Subjective information consists of a History of Present Illness (HPI) section which facilitates accurate diagnosis. In this case, information that should be added in this section include the presence of constipation alternating with diarrhea, the history of any chronic constipation in the past as well as the color of the stool and when it is presented either towards the end, beginning or in the middle of defecation. Moreover, the nurse should inquire about the presence of mucous in the stool, pain and melena during defecation and the location of the pain together with when it occurs and whether it gets relieved after defecation. Assessment 1: Assessing the Abdomen Essay
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In addition, the continence of fecal material, the presence of hemorrhoids and its status should be determined. Identification of tenesmus presence, the passing flatus and any peri-anal ulceration, weight loss, nausea and vomiting, heartburn, indigestion, hematemesis and urinary symptoms such as incontinence, urgency, frequency, hematuria and dysuria should be added. Furthermore, any joint pains or swellings and stiffness on wrist and hands, ankles and knees should be reported and when they occur.
Additional information on Past Medical History of the client entails the determination of history of dupuytren’s disease and thickening of Archilles tendon, chronic constipation , rheumatoid arthritis , dyspepsia and, hyperlipidemia. On review of systems (ROS), more information is required on the neurological, cardiovascular, respiratory, gastrointestinal and, genitourinary systems (Dyson, 2017). Furthermore, hematological, musculoskeletal, endocrine and reproductive system status should be added.
In order to prevent misdiagnosis, more information should be added to the objective information. This includes the presence of abdominal tenderness to palpation, and respiration.
The assessment is not supported by the objective and subjective information. This is because; the information provided acquired from the client is limited and thus not sufficient for the assessment. More tests should be carried out to prevent misdiagnosis since the symptoms of the illness overlap with those of other abdominal diseases (Dündar et al, 2018).
Appropriate diagnostic tests in this case would include inflammatory markers like CRP/ESR and ultrasound which facilitates the diagnosis of diverticulitis (Hasani et al., 2015). The urinalysis test is also effective in demonstrating the microscopic hematuria or pyuria in the patient. Moreover, abdominal flat plate x-ray identifies bowel obstruction evidence as well as air under the diaphragm. CBC also shows leukocytosis with left shift while CT scans with contrast diagnosis diverticulitis. Endoscopy is essential in ruling out the upper GI bleeding. Sigmoidoscopy test also can be done. It involves blood test to detect raised ESR/CRP and neutrophilia. Spiral CT of lower abdomen test is effective in providing additional information about the formation of fistula and thickening of the colonic wall (Kılınçer et al., 2017). Colonoscopy can also be employed to examine the rectum and the colon for gastrointestinal symptoms which includes change in bowel habits as well as intestinal bleeding. Assessment 1: Assessing the Abdomen Essay
I would reject the current diagnosis. This is because; it is based on limited information and diagnosis of the patient and thus, this may result in misdiagnosis. In addition, this would increase the safety risk of the patient since medical errors result in the formulation of wrong treatment plans. This could worsen the client’s condition and eventually result to death.
The possible conditions that may be considered as a differential diagnosis for this patient include differentials of change in bowel habits. This will help determine if the cause of pain in the abdomen is related to bowel problems. Diet change could be a cause of abdominal problems due to reactions and allergies. In this case, a change in diet is characterized by decrease in fluid intake as well as consumption of low fiber can help identify stomach reactions to specific food types (Friedrichsdorf et al., 2016). The inflammatory bowel disease (Crohn’s/ ulcerative colitis) can also differentiate the diagnosis of the client.
Dündar, Z. D., Dogrul, A. B., Ergin, M., & Dogrul, R. T. (2018). Abdominal Pain in Older Patients. In Geriatric Emergency Medicine (pp. 217-234). Springer, Cham.
Dyson, T. (2017). Abdominal Pain. In Primary Care for Emergency Physicians (pp. 153-162). Springer, Cham.
Friedrichsdorf, S., Giordano, J., Desai Dakoji, K., Warmuth, A., Daughtry, C., & Schulz, C. (2016). Chronic pain in children and adolescents: diagnosis and treatment of primary pain disorders in head, abdomen, muscles and joints. Children, 3(4), 42.
Hasani, S. A., Fathi, M., Daadpey, M., Zare, M. A., Tavakoli, N., & Abbasi, S. (2015). Accuracy of bedside emergency physician performed ultrasound in diagnosing different causes of acute abdominal pain: a prospective study. Clinical imaging, 39(3), 476-479.
Kılınçer, A., Akpınar, E., Erbil, B., Ünal, E., Karaosmanoğlu, A. D., Kaynaroğlu, V., … & Özmen, M. (2017). A new technique for the diagnosis of acute appendicitis: abdominal CT with compression to the right lower quadrant. European radiology, 27(8), 3317-3325. Assessment 1: Assessing the Abdomen Essay
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