Assessing the Abdomen Assignment Essay

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping Assessing the Abdomen Assignment Essay.

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.

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 Assessing the Abdomen Assignment Essay.
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)
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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, hyperctive bowel sounds, pos pain in the LLQ
Diagnostics: None
ASSESSMENT:

Left lower quadrant pain
Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To prepare:

With regard to the SOAP note case study provided:

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.
To complete:

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 3 different references from current evidence-based literature.
Use this refences in the paper

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel\’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)

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 Assessing the Abdomen Assignment Essay .

Chapter 3 “Abdominal Pain” (pp. 11-32)

And three (3) different references from current evidence based literature. to surpoute the last qetion in the instructions.

Abdominal pain is a presentation in many medical conditions. It has a high potential for misdiagnosis which can be hazardous. Therefore, it’s crucial to obtain comprehensive subjective and objective data in patients presenting with abdominal pains. This is so as to make an accurate and prompt diagnosis for proper management of the patient. Also, it enables one rule out other differential diagnosis. Additional subjective data would be obstetric and gynecological history which includes the age of menarche parity, fertility treatment, mode of delivery, menstrual circle, LMP, use of family planning (IUCD, exams like pap and self-breast examination (SBE). Menstruation history helps rule out ectopic pregnancy. Health maintenance and immunization history is also important. It includes any regular vaccines, exercise, and diet habits. (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Additional objective data entails a comprehensive review of systems (ROS) noting the positive and negative findings. Examining the HEENT for pallor, headaches, fatigue, ear pains, eye pains, and chest pains, loss of taste, nausea, and sore throat is important. Abdominal palpation is done to exclude abdominal wall or intra-abdominal masses. Performing percussions would help rule out other abnormalities like ascites, size of abdominal masses, and hepatomegaly. A digital rectal examination would help check for bleeding or other anomalies. A pelvic exam would be done to check for any palpable mass and rule out gynecologic problems. Genitourinary examinations are done to rule out any abnormalities. Lastly, obesity is a risk factor for diverticulitis therefore it is vital to include BMI calculations (Dains, Baumann, & Scheibel, 2016)

The assessment is supported by the by the subjective and objective data. In subjective data, patient complained of severe abdominal pains, diarrhea and nausea. Objective data revealed soft abdomen, hyperactive bowel sounds and localized pain in the lower left quadrant.

Diagnostic tests are done to confirm the diagnosis of diverticulitis. Laboratory tests such as; complete blood count to check for elevated white blood cell count and reduced hematocrit common in diverticulitis, liver tests to exclude cholelithiasis, cholecystitis and other causes of abdominal pain. A urine test is done to check for infection agents. Diagnostic imaging tests for diverticulitis includes an abdominal x-ray and ultrasound and a computed tomography scan with oral and intravenous contrast media used for diagnosing the cause of left lower quadrant (LLQ) pain that may be similar to diverticulitis. Magnetic resonance imaging is done to check for abscess or fistula associated with diverticulitis. Also, colonoscopy is done to confirm the extent of diverticulitis or rule out other malignancies (National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 2016). A pregnancy test would be done to rule out pregnancy and its related complications Assessing the Abdomen Assignment Essay.

The subjective and objective data supports the diagnosis of diverticulitis. This is because it presents with severe abdominal cramping, diarrhoea, nausea, localized pain in the lower left quadrant (NIDDK, 2016). This was noted in the patient.

There are various differential diagnoses for diverticulitis. The first differential diagnosis is acute appendicitis with colon involvement. It is a common emergency medical condition where the appendix is infected or obstructed. It presents with acute cramping abdominal pains in the right lower quadrant, gastrointestinal disturbance, nausea and vomiting (Hatipoglu, Hatipoglu, & Abdullaye, 2014). The patient complained of acute abdominal pains usually associated with appendicitis. The second differential diagnosis is Crohns Colitis, an inflammatory bowel disease that presents with fever, acute cramping pains, nausea and vomiting, and lower sided abdominal pains (Ananthakrishnan et al, 2016).The patient had similar presentations making it a probable diagnosis. The third is colorectal cancer which a common condition presenting with abdominal pains, changes in bowel movement, diarrhea, rectal bleeding, and bloodstained stool (Granados-Romero JJ et al, 2017) Assessing the Abdomen Assignment Essay .

In conclusion, abdominal pains are a common presentation in women of reproductive age. Correct and prompt diagnosis of abdominal pain can be difficult. Obtaining correct comprehensive subjective, objective and assessment data assists the physician to make the right diagnosis and provide the appropriate management.

References

Ananthakrishnan, A. et al. (2016).Systematic review and meta-analysis: phenotype and clinical outcomes of older-onset inflammatory bowel disease. J. Crohns Colitis, 10 (10) (2016), pp. 1224-1236

Ball, J. Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel\’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

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.

Granados-Romero JJ, Valderrama-Treviño AI, Contreras-Flores EH, Barrera-Mera B, Enríquez MH, Uriarte-Ruíz K, et al. (2017 ).Colorectal cancer: a review. Int J Res Med Sci; 5:4667-76. Colorectal cancer: a review (PDF Download Available). Retrived from: https://www.researchgate.net/publication/320676335_Colorectal_cancer_a_review

Hatipoglu, S., Hatipoglu, F., & Abdullayev, R. (2014). Acute right lower abdominal pain in women of reproductive age: Clinical clues. World Journal of Gastroenterology : WJG, 20(14), 4043–4049. http://doi.org/10.3748/wjg.v20.i14.4043

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).(2016). Diverticular Disease. National Institutes of Health Assessing the Abdomen Assignment Essay.

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