Lab Assignment: Assessing the Abdomen Essay

Lab Assignment: Assessing the Abdomen Essay

 

Additional subjective data

It is essential to understand the associated symptoms of the pain, such as sweating, headache, or weakness. In addition, aggravating and alleviating factors for the pain should be included. The patient should also describe the pain characteristics as pressing, crushing, or pressing. The care provider should also assess for any weight changes, such as loss of weight and appetite.

Additional Objective data

Additional objective data include any visible skin color changes, visible masses or injury, and engorged veins (Ball et al., 2019). Palpating organs to determine guarding and organomegaly could also help accurately diagnose the patient. Another assessment includes any pain elicited during movement and urine and fecal clearance. The data will help develop a definitive diagnosis.

Assessment

The objective and subjective data support the left lower quadrant pain assessment. The patient guards and groans when the left lower quadrant is touched. He complains that the pain is usually high at times (9/10). Pain location and characteristics are vital to diagnosing a patient. Pain in the lower left quadrant could represent many illnesses, such as left glomerulonephritis and bowel inflammatory disease. Gastroenteritis entails inflammation of the stomach and intestine, leading to excruciating pain. According to Sattar and Singh (2021), nausea and vomiting are common in gastroenteritis, and they are accompanied by diarrhea, often due to indigestion due to the digestive system compromise. The historical appearance of vomiting and diarrhea meets the diagnostic criteria for the condition. The pain can be located in the upper or lower quadrants, depending on whether the stomach or the intestines are inflamed. In addition, the patient has a history of GI bleeding, thus at high risk for developing gastroenteritis.

Diagnostic tests

• The diagnostic tests appropriate for this case are a stool culture for microorganism identification
• WBCs to diagnose or rule out inflammation or internal bleeding.
• Electrolytes to determine imbalance and severity- the patient had diarrhea
• Serology for long-term infections
• Stool examination for cysts to rule out abdominal cysts or parasites
• Radio imaging through an x-ray or a CT would help determine structural anomalies such as a diverticulum of inflammation. These tests would be integral for the diagnosis and management of the patient.

Actual Diagnosis Analysis

I would not accept the current diagnosis of Abdominal aortic aneurysm. Golledge (2019) notes that AAA is asymptomatic in most patients, and only about ¼ of the patients show symptoms, including pulsating pain near the navel, deep constant abdominal pain, and back pain. The pain in AAA is constant and does not change like the situation with our client. Escalation of the symptoms occurs when the aneurysm ruptures leading to disabling pain and internal hemorrhage, which can be potentially fatal.

Possible diagnoses or differentials include;

1. Gastroenteritis. The patient characteristics match gastroenteritis presentation. The patient has generalized pain and reports pain and nausea after eating. The condition causes indigestion, which causes nausea and vomiting in the patient. Thus, gastroenteritis is the most appropriate diagnosis.
2. Gastritis is another differential diagnosis of interest. The condition results from an inflation of the stomach lining. The pain is sharp in the left and right upper quadrants. Gastritis symptoms include nausea, abdominal pain, bloating, indigestion, and vomiting (Azer and Akhondi, 2021). The pain is explained as a burning sensation in the stomach. The patient presents with generalized pain, which is non-constant. Gastritis symptoms are sudden and disabling, unlike gastroenteritis, which presents with less severe symptoms that can resolve independently.
3. The last differential diagnosis is GERD. According to Clarrett and Hachem (2018), gastroesophageal reflux disease is caused by the regurgitation of gastric contents into the throat. The contents are acidic and burn the throat hence a period of intense pain and, at times hoarse voice. Heard presents with excruciating intermittent pain, which often occurs after eating. The pain reports abdominal pain but denies hoarseness of regurgitating gastric contents. He also denies other symptoms such as dysphagia, odynophagia, cough, or sore throat. Healthcare providers must know about abdominal assessments and disease presentation for accurate diagnosis.
   

References

Azer, S. A., & Akhondi, H. (2021). Gastritis. In StatPearls [Internet]. StatPearls Publishing.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2021). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences.

Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine, 115(3), 214. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/

Golledge, J. (2019). Abdominal aortic aneurysm: update on pathogenesis and medical treatments. Nature Reviews Cardiology, 16(4), 225-242. https://doi.org/10.1038/s41569-018-0114-9

Sattar, S. B. A., & Singh, S. (2021). Bacterial Gastroenteritis. In StatPearls [Internet]. StatPearls Publishing.

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Abdominal Assessment Lab Assignment:

By Day 1 of Week 6

In this Assessment 1 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. Just add in what you want to this case to make it unique to you. Do not use NA or normal. Welcome to Week 6. This week, your students will complete an analysis of the SOAP note provided. You can even write this up as a narrative so that you are able to correctly explain your analysis.

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

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• Gastroenteritis
Assignment 1: Lab Assignment: Assessing the Abdomen

Photo Credit: Getty Images/Hero Images
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 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:
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.

 

Excellent Good Fair Poor

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.
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.
7 (7%) – 9 (9%)
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.
4 (4%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation.
0 (0%) – 3 (3%)
The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
7 (7%) – 9 (9%)
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.
4 (4%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.
0 (0%) – 3 (3%)
The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
14 (14%) – 16 (16%)
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
11 (11%) – 13 (13%)
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.
8 (8%) – 10 (10%)
The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.
0 (0%) – 7 (7%)
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing explanation.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
18 (18%) – 20 (20%)
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.
15 (15%) – 17 (17%)
The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis.
12 (12%) – 14 (14%)
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.
0 (0%) – 11 (11%)
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of how the test results would 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 differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
23 (23%) – 25 (25%)
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature.
20 (20%) – 22 (22%)
The response states whether to accept or reject the current diagnosis, with an accurate explanation of sound reasoning. The response accurately identifies three conditions as a differential diagnosis, with reasoning that is explained accurately using three different references from current evidence-based literature.
17 (17%) – 19 (19%)
The response states whether to accept or reject the current diagnosis, with a vague explanation of the reasoning. The response identifies two or three conditions as a differential diagnosis, with reasoning that is explained vaguely and/or inaccurately using three references from current evidence-based literature.
0 (0%) – 16 (16%)
The response inaccurately or is missing a statement of whether to accept or reject the current diagnosis, with an explanation that is inaccurate and/or missing. The response identifies two or fewer conditions as a differential diagnosis, with reasoning that is missing or explained inaccurately using three or fewer references from current evidence-based literature.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 (5%) – 5 (5%)
Uses correct APA format with no errors.
4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.