NURS 6512 Lab Assignment Assessing The Abdomen

NURS 6512 Lab Assignment Assessing The Abdomen

NURS 6512 Lab Assignment Assessing The Abdomen

The SOAP note gives the case of a 47-year-old male who presented with stomach pain and diarrhea that began three days ago. The patient’s abdomen is soft on physical exam and has hyperactive bowel sounds (BS) and LLQ tenderness. The purpose of this assignment is to examine the SOAP note and identify the needed additional information and discuss likely diagnoses.

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Subjective Portion

The HPI should have described the abdominal pain, including duration, timing, characteristics, exacerbating, and alleviating factors. In addition, it should provide information describing diarrhea, including the onset, timing, frequency, and characteristics, such as if it is bloody, watery, mucoid, or malodorous. The subjective part should also have the patient’s surgical history and immunization status. Besides, the social history should have provided additional information like the patient’s occupation, education level, hobbies, and health promotion practices. Lastly, a review of systems (ROS) is missing, including the pertinent positives and negatives not provided in the HPI.  

Objective Portion

The objective section should have the patient’s general assessment, which includes hygiene, appearance, alertness level, facial expressions, body language, speech, and attitude. A focused abdomen exam should include comprehensive findings from the abdominal exam. Thus, it should have provided findings from inspection like the abdomen’s pigmentation, symmetry, contour, scars, and visible masses or peristalsis. In addition, findings from abdominal percussion and palpation should be provided, like the liver span, spleen position, presence of masses, organomegaly, guarding, or rebound tenderness.

Assessment Portion

LLQ pain is backed by the physical exam finding of tenderness in the LLQ but does not align with the patient’s symptom of generalized abdominal pain. Gastroenteritis (GE) is supported by subjective and objective findings, including generalized abdominal pain, diarrhea, nausea, and hyperactive BS.

Diagnostic Tests

Diagnostic tests suitable for this client Complete blood count (CBC) and stool culture test. CBC will be used to identify the white blood cell count, establishing the presence and cause of infection (Geyer, 2020). The stool test will establish the presence of blood, bacteria, viruses, or parasites in the stool, which will help determine the cause of the GI symptoms.

Diagnosis

GE is an acceptable diagnosis due to pertinent symptoms of abdominal pain, diarrhea, hyperactive BS, mild fever (99.8 F), and abdominal tenderness of palpation. On the other hand, I would disregard LLQ pain as a diagnosis since it is a physical exam finding indicating an underlying disorder.   

The probable diagnoses for this case are:

Acute Diarrhea: Acute diarrhea is characterized by an abrupt onset of three or more loose or watery stools per day. Patients may present with dehydration, nonspecific abdominal cramping or pain, flatulence, increased BS, abdominal tenderness worsened by palpation, and perianal erythema (Drancourt, 2018). Acute diarrhea is a likely diagnosis based on the patient’s diarrhea, generalized abdominal pain, and abdominal tenderness on palpation.

Gastroenteritis: GE occurs due to inflammation of the stomach lining. It is associated with vomiting, anorexia, nausea, diarrhea, abdominal pain/tenderness, and hyperactive BS (Bányai et al., 2018). Findings of abdominal pain, diarrhea, nausea after meals, and hyperactive BS make GE a possible diagnosis.

Colonic Diverticulitis: Patients with colonic diverticulitis have LLQ abdominal pain and tenderness, a palpable sigmoid, nausea, vomiting, fever, rebound, and guarding (Tursi et al., 2020). Thus, it is a likely diagnosis owing to the patient’s mild fever, nausea, and LLQ pain.

Conclusion

The subjective part should have additional information describing the abdominal pain and diarrhea. Physical findings from the general assessment and detailed abdominal exam should have been provided. Possible diagnoses include acute diarrhea, GE, and colonic diverticulitis.

References

Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175-186. https://doi.org/10.1016/S0140-6736(18)31128-0

Drancourt, M. (2018). Acute Diarrhea. Infectious Diseases, 335–340.e2. https://doi.org/10.1016/B978-0-7020-6285-8.00038-1

Geyer, B. (2020). Diagnosis and management of acute gastroenteritis in the emergency department. Emergency medicine practice, 22(3), 1–24.

Tursi, A., Scarpignato, C., Strate, L. L., Lanas, A., Kruis, W., Lahat, A., & Danese, S. (2020). Colonic diverticular disease. Nature reviews. Disease primers, 6(1), 20. https://doi.org/10.1038/s41572-020-0153-5

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Assessing the Abdomen

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. Just add in what you want to this case to make it unique to you. Do not use NA or normal.

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: ?
Assessment:
• Left lower quadrant pain
• Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512)
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:
o Review this week’s Learning Resources, and consider the insights they provide about the case study.
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. 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.