NURS 6512 Week 6 Assignment: Assessing the Abdomen

NURS 6512 Week 6 Assignment: Assessing the Abdomen

NURS 6512 Week 6 Assignment: Assessing the Abdomen

A male went to the emergency room for severe midepigastric 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.

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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

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.

The case:

CC: “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

FH: 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

NOTE:

Subjective data:

Trigger factor

>Relief measures done?

>Aggravating factors?

>Timing of the pain?

>Pain scale?

>Characteristic of the vomitus, amount.

>What PPI? Dose etc.

>Presence or absence of blood in stool

ï‚· Quality and frequency of normal BM’s

ï‚· Dietary information

ï‚· Average daily fluid intake

ï‚· Exposure to illness

ï‚· Recent travel

>Past medical hx: needs when diagnosed? Controlled or uncontrolled? Usual BP range?

>Metoprolol frequency. Compliance to medication.

>Add PPI administered

>Family hx clarify which familial side

>Specific amount of drink, type of alcohol, frequency. Smoke pack years missing.

>Living situation, financial situation, insurance?

Objective

Abdominal inspection – symmetry, skin color

 Light palpation – pain, guarding, distension

 Deep palpation – pain, masses

>need BMI

>Inspection, Auscultate, Percuss, palpate

>CBC

>Stool sample bacterial/viral and occult blood