Posted: November 13th, 2022
Assessment of the Abdomen and Gastrointestinal System.
Assessment of the Abdomen and Gastrointestinal System ABDOMINAL ASSESSMENT Subjective: CC: “My stomach hurts, I have diarrhea, and nothing seems to help.” History of Present Illness (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. Past Medical History (PMH): HTN, Diabetes, hx of GI bleed 4 years ago Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs Allergies: NKDA Family History (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 Assessment Left lower quadrant pain Gastroenteritis PLAN: This section is not required for the assignments With regard to the SOAP note case study provided, address the following: Assessment of the Abdomen and Gastrointestinal System.
• 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 differential diagnosis for this patient.Assessment of the Abdomen and Gastrointestinal System. • Explain your reasoning using at least three different references from current evidence-based literature. References (Required) 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. Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis. Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.Assessment of the Abdomen and Gastrointestinal System.
Assessment of the Abdomen and Gastrointestinal System
Assessment is an important part of the treatment process. This process enables healthcare providers to gather critical patient’s information, which is required for the diagnosis and treatment process (Dains, Baumann & Scheibel, 2019). In this case, assessing the gastrointestinal system and abdomen of the patient will enable the practitioner to gather the required data. This information will, in turn, aid in the treatment process. Additionally, the paper will analyze both subjective and objective portions of the note, indicating whether this information supports the assessment process. Appropriate diagnostic tests, stand about the current diagnosis, and differential diagnosis will be addressed.Assessment of the Abdomen and Gastrointestinal System.
The subjective portion
The subjective section of the assessment note covers all information and symptoms that are given from the client’s point of view. In most cases, practitioners gather subjective data during clinical interviews (LeBlond, Brown & DeGowin, 2014). These details include the client’s feelings, concerns, and perceptions. In this scenario, the subjective information provided by the client is “severe abdominal cramping.” More subjective information should be added to the documentation. This information includes the duration of pain, cases of nausea and vomiting, an incident of fever, cases of abdominal tenderness, constipation, or diarrhea. According to Walter et al. (2016), abdominal pain that radiates to the back signifies abdominal complications. Additionally, the healthcare provider should document incidents of loss of appetite, whites in the eyes and yellowing of the skin as well as incidents of dark-colored urine and light-colored stools.Assessment of the Abdomen and Gastrointestinal System.
The objective portion
Objective data also assists during diagnosis and treatment processes. The clinician gathers objective information of the client through physical examination and diagnostic testing. In this case, objective information is portrayed by a growth in the pancreas. This information was revealed through a CT scan. More objective data should be documented to enhance the treatment process. This information includes the interpretation of abdominal X-ray, the report of percussion, and the results of amylase and lipase tests, the results of the pregnancy test as well as the results of complete blood count and pancreatic enzymes tests.
How does subjective and objective information support the assessment?
This information enhances the assessment process. First, growth in the pancreas is characterized by persistent abdominal pain. Persistent abdominal pain was the chief complaint that was presented by the patient. Additionally, the physician used computerized tomography (CT) scan to diagnose the condition. CT scan is among the major imaging tests that enable practitioners to capture the pictures of the internal organs of the patient during diagnosis.Assessment of the Abdomen and Gastrointestinal System.
Appropriate Diagnostic Tests
An upper gastrointestinal endoscopy would be the first appropriate diagnostic test for this case. This test would enable the practitioner to view the inner lining of the client’s digestive tract. Also, a CT scan would be appropriate in this case. It would enable the clinician to evaluate the swollen region within the abdomen (Colyar, 2015). Furthermore, a barium X-ray of the small intestine would be appropriate. It would enable the clinician to establish the cause of the intestinal swelling. The results of the X-ray indicated that the small intestine was normal. Additionally, the barium X-ray would be used to evaluate the client’s large intestine. A narrowing was identified in the middle of the colon, which indicated that the CT scan was misinterpreted. Besides, multiple laboratory tests such as complete blood count (CBC), pregnancy, liver enzymes, pancreatic enzymes, and urinalysis would be appropriate for this case. Finally, it would be recommendable to conduct Endoscopic ultrasound (EUS) and Magnetic resonance imaging (MRI) tests. The results of these tests would enhance the diagnosis and management of this condition. An increase in the level of pancreatic enzymes by more than three times normal levels would indicate damage in the pancreas. Secondly, the presence of amylase or lipase in the blood at levels higher than normal indicates damage in the pancreas. Lastly, the CT scan shows the damaged region, thus indicating the spread of pancreatic cancer.Assessment of the Abdomen and Gastrointestinal System.
Stand about the Current Diagnosis
I would reject the results provided by the current diagnosis. First, the patient only complains of severe abdominal pain, which could characterize other conditions such as ectopic pregnancy, constipation, Irritable bowel syndrome (IBS), food poisoning, pelvic inflammatory disease, kidney stones, Crohn’s disease or ulcerative colitis. Besides, the practitioner ought to have conducted another test to confirm the results of the CT scan before ruling out that the patient had pancreatic cancer. An error might have occurred while performing the test, or the results of the test could have been misinterpreted.
Differential diagnosis would assist the practitioner in ruling out the condition of the patient. Irritable bowel syndrome (IBS) would be the first differential diagnosis. Both pancreatic cancer and IBS are characterized by pain and cramping in the abdominal area. Abdominal pain is the primary symptom that is used in the diagnosis of Irritable bowel syndrome (Sayuk & Gyawali, 2015). Additionally, IBS is characterized by multiple symptoms, including diarrhea, constipation, gas and bloating, change in bowel movement, food intolerance as well as fatigue, and difficulty in sleeping. The second differential diagnosis involves pelvic inflammatory disease. Individuals who are suffering from this condition experience severe abdominal pain (Brunham, Gottlieb & Paavonen, 2015). This condition is also characterized by pain in the upper abdomen. The last differential test involves Crohn’s disease. According to Plavšić, Štimac and Hauser (2016), individuals with this condition experience severe abdominal pain.Assessment of the Abdomen and Gastrointestinal System.
Initials, Age, Sex, Race
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.Assessment of the Abdomen and Gastrointestinal System.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.Assessment of the Abdomen and Gastrointestinal System.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Assessment of the Abdomen and Gastrointestinal System.
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