NURS 6512 Week 6 Assignment
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
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.
Welcome to Week 6. You will complete an analysis of the SOAP note provided. This can be written in narrative or SOAP note format. Analyze the subjective and objective section of the note and list any additional information that should be included. Review syllabus for additional information to include.
INSTRUCTIONS
Assignment 1: Lab Assignment: Assessing the Abdomen
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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.
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
With regard to the Episodic 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.
The Assignment
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 three different references from current evidence-based literature.
Rubric
Name: NURS_6512_Week_6_Assignment_1_Rubric
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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.–
Excellent 10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.
Good 7 (7%) – 9 (9%)
NURS 6512 Week 6 Assignment
Additional Subjective Information
Additional subjective information is necessary since the patient failed to describe the pain comprehensively. The patient did not mention the exact location of the abdominal pain. While rating the pain, he failed to describe the pain, such as throbbing, sharp, shooting, or cramping. The patient did not describe what happened when the pain started. He did not explain the kinds of foods that trigger the pain. He did not explain how long the pain lasts and elevating factors, including defecating or belching. The patient needs to provide a review of systems to ensure a comprehensive assessment.
Subjective Review of Systems
General: No weight loss or gain, fever, or fatigue.
HEENT: No vision loss, yellow sclera, or blurred vision. No hearing problems. No running nose. No tonsillitis.
Skin: No lesions, itching, or rashes.
Cardiovascular: No edema, chest pressure, discomfort, or chest pain.
Respiratory: No shortness of breath, coughing or sputum.
Gastrointestinal: Abdominal pain with nausea and diarrhea. No vomiting.
Genitourinary: No urinary problems.
Neurological: No headache, seizure, change of bladder control.
Musculoskeletal: No muscle pain or stiffness.
Hematologic: No anemia or bruising.
Lymphatics: No enlarged nodes or splenectomy.
Psychiatric: No depression or anxiety.
Endocrinologic: No reports of sweating, polyuria or dysuria.
Allergies: No history of eczema, rhinitis or asthma.
Additional Objective Information
A thorough assessment of the patient should comprise an examination of the groin. The purpose is to exclude incarcerated hernia or testicular torsion as the possible causes of pain. It involves percussing to determine the tenderness or flanks (Jackson & Cruz, 2018). For instance, flank pain can be an indicator of kidney stones. A provider should examine genital and prostrate parts to rule out sexually transmitted diseases. A nurse should check fecal occult or frank blood. For instance, the presence of blood may indicate the presence of carcinoma or an acute condition (Jackson & Cruz, 2018). Abdominal pain may be referred to other organs or parts, and an examination of the heart, lungs, head, and neck is necessary.
Is the Current Diagnosis Acceptable?
The current diagnosis does not meet a required threshold of further tests and examinations. Gastroenteritis can be diagnosed using subjective and objective information, but the advanced nurse practitioner should carry additional tests to rule out other possible conditions (Dains et al., 2018). For example, gastroenteritis patients experience diarrhea, fever, vomiting, hyperactive bowel sounds, and nausea. The patient in the case study has not mentioned about vomiting. Gastroenteritis can resolve without treatment.
Diagnostic Tests
A complete history of the patient is necessary before the diagnostic tests. Laboratory tests are not needed. However, patients with persistent fever or blood in their stool or urine may require further tests (Dains et al., 2018). Some of the tests that may be helpful in the diagnosis include X-rays or CT scans.
Differential Diagnosis
The vague symptoms from the information provided by the patient could indicate other conditions such as irritable bowel syndrome, bowel obstruction, and ureterolithiasis.
Irritable bowel syndrome – Irritable bowel syndrome is a common disorder characterized by diarrhea, bloating, constipation, and abdominal cramping. A bowel examination and blood test are essential for the patient (Brady & Pade, 2018). The blood test is negative if the condition is not present. An advanced nurse practitioner should consider the history of colorectal cancer and the age of the patient. Other considerations include if the stool is positive for blood or failure to show improvement between 6-8 weeks (Brady & Pade, 2018). The considerations will lead to proctosigmoidoscopy.
Bowel obstruction – The condition occurs among people with a history of recent GI surgery, elderly, and babies. Some of the obstruction causes include adhesions that occur after surgery, colon cancer, hernia, and diverticulitis (Brady & Pade, 2018). Patients present with sudden crampy pain. Patients experience vomiting. Obstipation occurs while diarrhea happens with partial obstruction. Hyperactive bowel sounds are present upon obstruction. Abdominal distention is present in case of obstruction (Reddy & Cappell, 2017). An advanced nurse practitioner should take X-rays, MRI, or CT scan to diagnose the condition.
Ureterolithiasis – The condition occurs when kidney stones occur in the ureters. Patients with the condition report an excruciating colicky pain that can progress to the constant pain. Patients experience pain in the lower abdomen and groin (Brady & Pade, 2018). Other symptoms include vomiting, chills, and abdominal distention. Patients also experience hematuria and urinary frequency. Diagnosis includes urinary analysis to determine the urine pH and analyze the stone composition (Brady & Pade, 2018). Another diagnosis is a non-contrast-enhanced helical computed tomography CT scan.
References
Brady, K., & Pade, K. H. (2018). Acute gastroenteritis: evidence-based management of pediatric patients [digest]. Pediatric Emergency Medicine Practice, 15(2 Suppl Points & Pearls), 1-2.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2018). Advanced Health Assessment & Clinical Diagnosis in Primary Care E-Book. Elsevier Health Sciences.
Jackson, P., & Cruz, M. V. (2018). Intestinal obstruction: evaluation and management. American Family Physician, 98(6), 362-367.
Reddy, S. R. R., & Cappell, M. S. (2017). A systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction. Current Gastroenterology Reports, 19(6), 28.
