NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System Essay
NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System Essay
Abdominal Assessment
Abdominal pain is a common complaint in patients presenting in the primary healthcare setting. Sometimes, the signs and symptoms associated with abdominal pain pose a diagnostic and therapeutic dilemma for healthcare providers. As such, a thorough assessment of subjective and objective data is vital to arrive at a correct diagnosis, thus implementing an effective treatment plan. In the case study note, crucial information is missing in the subjective and objective portions. This paper discusses the information missing in the subjective and objective portions, appropriate diagnostic tests, and differential diagnosis.
Additional Information That Should Be Included in The Subjective Portion
The patient provides additional information about the condition in the subjective portion of the soap note. In the HPI section, some missing details may be essential in identifying possible diagnoses. The information missing includes whether the patient has previously experienced similar symptoms, whether the pain is constant or intermittent, the triggers, alleviating and aggravating factors, and the severity levels of the pain (Govender et al., 2021). The PMI section lacks details of past surgeries, hospitalization, and injuries. It also ignores the age when the patient was diagnosed with hypertension.
A thorough, comprehensive history is also important; it involves the medical history of first-degree relatives. The information given on FH should include identifying family members with medical conditions. The data missing in the social history section is on the patient’s occupation, diet behavior, cultural beliefs, social determinant, and quantity of ETOH consumption. The section also lacks details about the PPIs prescribed at the emergency unit, including the name(s), dosage, frequency, side effects, supplements, vitamins, and over-the-counter drugs the patient might be taking (Govender et al., 2021). Lastly, the sections are missing information in the review of systems (ROS), moving from head to toe, only focusing on those systems related to the chief complaint. Since the patient CC is focused on the abdominal system, relevant questions may include GI disorder, heartburn, jaundice, bowel movement, and constipation.
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Additional Information That Should Be Included In The Objective Portion
In the objective portion, the information documented is based on the provider’s observation. According to Mealie et al. (2023), for abdominal objective data, inspection, auscultation, percussion, and palpation provide adequate information to generate findings that help identify possible diagnoses. In the soap note, information on the general survey on the patient and vital signs need to be included. The information on any skin changes needs to be included. The genitourinary section information should also be included as it is relevant to the chief complaint. The CC is related to the abdominal system; thus, a thorough assessment of the GI organ is fundamental. This information on the findings after observing and inspecting the abdominal shape, protrusions, color, auscultation, percussion, and palpation on all four quadrants needs to be included. Blood in stool should also be assessed for GI bleeding.
Does the Objective and Subjective Data Support the Assessment?
The subjective and objective data support pancreatitis and AAA as the assessment, while they do not support perforated ulcers. Pancreatitis is a condition characterized by pancreas inflammation causing severe upper abdominal pain. The clinical manifestation of pancreatitis includes severe upper abdominal pain radiating toward the back (Ashraf et al., 2021). The pain is usually sudden and severe. The information reveals that the patient experiences severe upper abdominal pain radiating to the back. In addition, the patient has a history of alcohol consumption which increases the risk for the condition, thus supporting the assessment. The Abdominal Aortic Aneurysm (AAA) results from the bulging outward of the abdominal aorta with more than 3 cm in diameter. The signs and symptoms of AAA include abdominal pain that radiates toward the back or side (Golledge et al., 2023). The patient information in the CC shows the patient has abdominal pain radiating toward the back, thus supporting the assessment. Lastly, a perforated ulcer is manifested by sudden onset of abdominal pain, rigidity, and tachycardia (Chung & Shelat, 2017). The patient does not have abdominal rigidity or tachycardia, thus not supporting the assessment.
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Appropriate Diagnostic Tests
Abdominal pain is associated with various health conditions, which makes it essential to carry out tests that identify the correct diagnosis. Some tests conducted include urine, stool, blood,s and imaging. However, the nature of the patient’s symptoms makes it possible to perform other tests, including; EKG, to help rule out abnormal heart findings. A CBC test is also essential for identifying any infection that might be present. C-reactive protein and hepatic tests would also be vital to show liver functioning (Govender et al., 2021). An X-ray may help in identifying the presence of kidney stones, gas, or constipation. A CT of the abdomen can also be conducted to rule out pancreatitis. Other tests that may be necessary are urine analyses and fecal blood screening. I would accept the diagnosis of pancreatitis based on the patient’s symptoms, such as abdominal pain that radiates to the back, while also considering that the patient has a history of alcohol consumption.
Pancreatitis: Pancreatitis manifests by severe upper abdominal pain, especially at the epigastric region that radiates towards the back. Patients complain of sharp severe pain associated with nausea and vomiting. The patient experiences severe upper abdominal pain in the epigastric area radiating to the back, making it a highly appropriate diagnosis.
Gastritis: The clinical manifestation of this condition includes nausea, vomiting, and upper abdominal pain. In addition, some factors, such as a history of alcohol consumption, increase the risk for gastritis. The patient has a history of alcohol use and complains of abdominal pains. Therefore, gastritis may be a potential diagnosis.
Abdominal Aortic Aneurysm (AAA): AAA’s signs and symptoms include abdominal pain radiating towards the back or side. It may be accompanied by blood loss due to the rupture, dizziness, and loss of consciousness. The patient information in the CC shows the patient has abdominal pain radiating toward the back, thus making it a likely diagnosis.
References
Ashraf, H., Colombo, J. P., Marcucci, V., Rhoton, J., & Olowoyo, O. (2021). A clinical overview of acute and chronic pancreatitis: The medical and surgical management. Cureus. https://doi.org/10.7759/cureus.19764
Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer – an update. World Journal of Gastrointestinal Surgery, 9(1), 1. https://doi.org/10.4240/wjgs.v9.i1.1
Golledge, J., Thanigaimani, S., Powell, J. T., & Tsao, P. S. (2023). Pathogenesis and management of abdominal aortic aneurysm. European Heart Journal. https://doi.org/10.1093/eurheartj/ehad386
Govender, I., Rangiah, S., Bongongo, T., & Mahuma, P. (2021). A primary care approach to abdominal pain in adults. South African Family Practice, 63(1). https://doi.org/10.4102/safp.v63i1.5280
Mealie, C. A., Ali, R., & Manthey, D. E. (2023). Abdominal exam. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459220/#
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A male went to the emergency room for severe mid-epigastric abdominal pain. He was diagnosed with AAA; however, as a precaution, the doctor ordered a CTA scan.
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
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:
**** **ABDOMINAL ASSESSMENT
Subjective:
Chief Complaint: “My stomach has been hurting for the past two days.”
HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.
PMH: HTN
Medications: Metoprolol 50mg
Allergies: NKDA
Family History: HTN, Gerd, Hyperlipidemia
Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female
Objective:
- VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
- Heart: RRR, no murmurs
- Lungs: CTA, chest wall symmetrical
- Skin: Intact without lesions, no urticaria
- Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound. Diagnostics: US and CTA
Assessment:
- Abdominal Aortic Aneurysm (AAA)
- Perforated Ulcer
- Pancreatitis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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.
- 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.
Week 6 Preparation for Mid term
This week, you will complete an analysis of the SOAP note provided. You may use narrative format.
In your SOAP note analysis, look for missing information, review each section, HPI, PMH, FH, SH, ROS and physical examination.
This week, midterm examination is due by Day 6. You can find an exam review guide for the midterm in the “Resources” section for this week. The exam will not be available until 7/3/2023 and will end promptly on the end date and time. This is a timed test and will end in 2 hours. Test is available after due date, however late points will be deducted, if you take test late. Do not wait until last minute to take test, make sure you have good internet access before you start examination. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this exam.
This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. This exam is timed with a limit of two hours for completion. The exam will not open until the day it is scheduled to open.