Assignment 1: Lab Assignment: Assessing the Abdomen

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:

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.

Follow the rubric…..Be sure to use APA format…..and upload by Day 7.

Episodic note case study

Subjective:•CC: “My stomach hurts, I have diarrhea and nothing seems to help.”• HPI: JR, 47 y/o 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

NURS 6512 Week 6 Assignment 1

Patient Information:

Initials: JR Age: 47 Sex: Male Race: Caucasian

S.

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.

Current Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs

Allergies: NKDA

PMHx: HTN, Diabetes, hx of GI bleed 4 years ago Soc Hx:. Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Fam Hx: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

O.

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, positive pain in the LLQ on palpation

Diagnostics: None

A.

Differential Diagnoses: Left lower quadrant pain, Gastroenteritis

Is the Current Diagnosis Supported by the Current Information?

The diagnosis of gastroenteritis cannot be supported by current information. The advanced practice nurse needs additional subjective and objective information to complete a proper assessment. Also, diagnostic testing needs to be ordered to rule out any other possible diagnoses.

Additional Subjective Information Needed

The patient is very vague about his abdominal pain. In his description he failed to mention the exact location of his abdominal pain. While rating his pain on a scale of 0 to 10 he failed to describe the pain he is feeling. Is the pain sharp, cramping, aching, shooting, stabbing or throbbing? What was the patient doing when the pain started? Are there any foods that aggravate the pain or cause it to flare up? How long does the pain last when it starts? Are there any alleviating factors such as belching or defecating? Does the patient have any problems urinating? Not only does the provider need more information from the patient about the chief complaint, he/she also needs the subjective review of systems (ROS) to complete a proper examination. The subjective ROS would be as follows:

Subjective Review of Systems:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  Abdominal pain with nausea. Denies any vomiting. States he has had a lot of diarrhea.

GENITOURINARY:  Denies any urinary issues.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

Additional Objective Information Needed

In order to complete a thorough assessment regarding an abdominal complaint the advanced practice nurse must examine a number of different systems in addition to what has already been assessed. The provider must examine the patient’s groin area in order to exclude an incarcerated hernia or testicular torsion (Dains, et al, 2016). The provider should also percuss for tenderness in the flanks. Flank pain can indicate a kidney stone. Genital and prostate examinations should be performed in men in order to rule out sexually transmitted infections (STIs) and prostatitis. The advanced practice nurse must also look for frank blood or fecal occult blood. The presence of blood can indicate an acute process or carcinoma. Because abdominal pain can be refereed from other areas, the provider should also examine the lungs, heart, head and neck, and musculoskeletal system (Dains, et al, 2016).

Is the Current Diagnosis Acceptable?

The current diagnosis is unacceptable without further assessment and testing. While gastroenteritis can be diagnosed via subjective and objective assessment data only (Dains, Bauman, Scheibel, 2015), the advanced practice nurse must rule out any other possible diagnosis. Usually patients with gastroenteritis have a diffuse, crampy abdominal pain accompanied by nausea, vomiting, diarrhea, and fever. The patient is afebrile with nausea and diarrhea, but has not informed the provider of any vomiting. According to Dains, et al, the patient with gastroenteritis will have hyperactive bowel sounds, which our patient does have. Gastroenteritis usually resolves without any treatment and requires no diagnostic testing.

Conditions That Could Be Considered a Different Diagnosis

The patient could be experiencing a number of abdominal issues. The patient has complained of diffuse abdominal pain with nausea and has hyperactive bowel sounds. These vague symptoms can also point to ureterolithiasis, bowel obstruction, or irritable bowel syndrome (IBS). Each condition requires specific diagnostic testing in order to form an accurate diagnosis.

1) Ureterolithiasis occurs when kidney stones form in the ureters. The patient reports the sudden onset of excruciating intermittent colicky pain that can progress to a constant pain (Dains, et al, 2016). The pain is in the lower abdomen and flank and radiates to the groin. The patient with ureterolithiasis may also have nausea, vomiting, abdominal distention, chills, and fever (Dains, et al, 2016). Hematuria and urinary frequency can also be present. A urinalysis can be done to determine urine pH and the presence of crystals can help identify stone composition. A definitive diagnosis is made via noncontrast-enhanced helical computed tomography (CT) scan.

2) Bowel obstruction occurs in newborns, the elderly, and those with recent GI surgery (Dains, et al, 2016). According to Mayo Clinic (2018), causes of intestinal obstruction may include adhesions in the abdomen that form after surgery, an inflamed intestine (Crohn’s disease), diverticulitis, hernias, and colon cancer. The patient usually presents with sudden onset of crampy pain. Vomiting usually occurs early with small intestinal obstruction and late with large bowel obstruction. Obstipation occurs with a complete obstruction, but diarrhea can be present with a partial obstruction (Dains, et al, 2016). Hyperactive, high-pitched bowel sounds can be present with a small bowel obstruction. A mass may be palpable in a lower obstruction. Abdominal distention can be present. Definitive diagnosis is made with abdominal x-rays, CT scan, or MRI.

3) Irritable bowel syndrome (IBS), or spastic colon, is a common disorder that is characterized by abdominal cramping, abdominal pain, bloating, constipation, and diarrhea (Mayo Clinic, 2017). The patient with IBS will have a normal bowel examination and the stool will be negative for blood. If the onset of IBS is at middle age or older, if the stool is positive for blood, if there is a family history of colorectal cancer or polyps, or if the patient fails to show improvement of symptoms after 6 to 8 weeks of therapy a proctosigmoidoscopy or barium enema (BE) should be considered (Dains, et al).

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Mayo Clinic. (2018). Intestinal obstruction. Retrieved from https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms- causes/syc-20351460

Mayo Clinic. (2017). Spastic colon: What does it mean?. Retrieved from https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/expert- answers/spastic-colon/FAQ-20058473

Episodic note case study

Subjective:•CC: “My stomach hurts, I have diarrhea and nothing seems to help.”• HPI: JR, 47 y/o 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

 
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