Case Study For Assessing The Abdomen Assignment

Case Study For Assessing The Abdomen Assignment

In this Assessment 1 Assignment, you will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. This is in a scholarly paper format and not SOAP format this week. 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. Follow the rubric…..Be sure to use APA format…..and upload by Day 7 Case Study For Assessing The Abdomen Assignment

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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)Case Study For Assessing The Abdomen Assignment

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

Most of the patient’s complaints on abdominal issues are indecisive and common. A precise ultimate analysis needs exhaustive breakdown of physical and analytical exams (Schnedl, et al, 2019). This paper tackles a patient who reports to the hospital complaining of a stomachache and diarrhea.

Additional subjective and objective data

There are extra facts that would aid in confirming a diagnosis. Subjective information on factors or conditions that lessen or aggravate the pain, how long the diarrhea has lasted, stool nature, recent diet change and existing food allergies (Schiller, et al, 2017). There should be objective information on the nature of the blood vessels. The aorta should be checked for any visible throb (Ballou, & Keefer, 2017)Case Study For Assessing The Abdomen Assignment. The rest of the information is competently taken. The comprehensive parents’ account aids in illuminating most of the prevailing patient’s disorders. The patient’s health history is also appropriately exhausted.

Support on the assessment

The chief complaints of the patient support the relevance of the collected subjective and objective information. Taken in the chief part of the personal valuation are the period, harshness, and pattern of the symptoms (Schiller, et al, 2017). The objective assessment covers the nature of the body vitals. Gastroenteritis diagnosis is acceptable. One justification is the chief complaint of abdominal pain in the left lower quadrant (Bányai, et al, 2018). The past does not expose any applicable conceivable disorders. The data given proposes gastroenteritis as the correct diagnosis.

Differential Diagnosis

The patient has to be assessed for acute appendicitis (Burgers, et al, 2020). Its symptoms include pain in the lower abdomen, nausea, diarrhea, vomiting, and loss of appetite. An ultrasound would be the effective way to diagnose the condition (Shin, et al, 2018). Viral meningitis which is caused by enteroviruses is another differential diagnosis. The infection has symptoms similar to those of gastroenteritis (Bányai, et al, 2018)Case Study For Assessing The Abdomen Assignment.

Another appropriate possibility would be IBS which is a disorder that is associated with stomach and the intestines infection. Its indications are diarrhea, abdominal pain, changes in abdominal movements, and exhaustion (Soh, et al, 2018). IBD is another more likely outcome. Its symptoms are diarrhea, tiredness, stomachache, melena, and weight loss (Ballou, & Keefer, 2017). Inconclusive information on the diarrhea state and a lack of additional diagnostics negate IBD as a likely final diagnosis.

Abnormal findings

The most abnormal discovery is the lessening of the abdominal pain without medical prescriptions or any patient’s intrusion (Schiller, et al, 2017). The additional diagnostic tests can shed light on the fact while clearing up any other abnormalities. The high blood pressure is a result of the existing hypertension disorder which is most likely biologically inherited. The agitated abdominal sounds might be due to the surge in intestinal action caused by the existing medical issue (Stuempfig, & Seroy, 2022). The account of prescriptions and disorders might be a catalyst to the current concern.

Appropriate Diagnostic Test

The only way to clearly account for a relevant diagnosis is additional diagnostic exams. The tests would be imaging diagnostics which can clearly show the state of the abdomen. Abnormalities such as tumors, lesions, injuries, infections, and obstructions can be detected (Ge, & Liu, 2020)Case Study For Assessing The Abdomen Assignment. Abdomen related imaging includes X-ray, CT scan, ultrasound, and endoscopy. A stool and urine test can help determine the nature of the stool for relevant assessment (Cuna, et al, 2018). The abdominal imaging is meant to focus on any defects on the kidneys, stomach, intestines, blood vessels, and bladder.

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Conclusion

Most of these differential diagnosis are a possibility. Additional diagnostics tests and information would help accept or reject them. If the tests do not show any abnormal findings, gastroenteritis is the correct final diagnosis (Ge, & Liu, 2020).

References

Schiller, L. R., Pardi, D. S., & Sellin, J. H. (2017). Chronic diarrhea: diagnosis

and management. Clinical Gastroenterology and Hepatology, 15(2), 182-193. https://www.sciencedirect.com/science/article/abs/pii/S1542356516305018

Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis.

The Lancet, 392(10142), 175-186. https://www.sciencedirect.com/science/article/abs/pii/S0140673618311280 Case Study For Assessing The Abdomen Assignment

Shin, D. W., Yoon, H., Kim, H. S., Choi, Y. J., Shin, C. M., Park, Y. S., … & Lee, D. H.

(2018). Effects of alkaline-reduced drinking water on irritable bowel syndrome with diarrhea: a randomized double-blind, placebo-controlled pilot study. Evidence-Based Complementary and Alternative Medicine, 2018. https://www.hindawi.com/journals/ecam/2018/9147914/

Ballou, S., & Keefer, L. (2017). Psychological interventions for irritable bowel syndrome

and inflammatory bowel diseases. Clinical and translational gastroenterology, 8(1), e214. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288603/

Ge, Y., & Liu, S. (2020). Ultrasound, X‑ray, computed tomography and clinical tests

for diagnosis of abdominal purpura in children: A retrospective study. Experimental and Therapeutic Medicine, 19(6), 3559-3564. https://www.spandidos-publications.com/etm/19/6/3559

Cuna, A. C., Reddy, N., Robinson, A. L., & Chan, S. S. (2018). Bowel ultrasound for

predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis. Pediatric radiology, 48(5), 658-666. https://link.springer.com/article/10.1007/s00247-017-4056-x

Ng, Q. X., Soh, A. Y. S., Loke, W., Lim, D. Y., & Yeo, W. S. (2018). The role of

inflammation in irritable bowel syndrome (IBS). Journal of inflammation research, 11, 345. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159811/

Burgers, K., Lindberg, B., & Bevis, Z. J. (2020). Chronic diarrhea in adults: evaluation

and differential diagnosis. American Family Physician, 101(8), 472-480. https://www.aafp.org/pubs/afp/issues/2020/0415/p472.html

Stuempfig, N. D., & Seroy, J. (2022). Viral gastroenteritis. In StatPearls [Internet].

StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK518995/

Schnedl, W. J., Lackner, S., Enko, D., Schenk, M., Holasek, S. J., & Mangge, H. Case Study For Assessing The Abdomen Assignment

(2019). Evaluation of symptoms and symptom combinations in histamine intolerance. Intestinal research, 17(3), 427-433. https://www.irjournal.org/journal/view.php?number=761&utm_source=TrendMD&utm_medium=cpc&utm_campaign=Intestinal_Research_TrendMD_1

Advanced Health Assessment

Lab tests, subjective, and objective, information is always crucial in a clinical setting since it helps clinicians make the right treatment decisions. Hence, the paper will address the additional subjective and objective data of the case scenario and the support this information has on the assessment, appropriate diagnosis, and differential diagnosis for the patient.

Additional Subjective Data

Subjective data refers to the information a patient provides to the healthcare providers during a clinical visit. According to Jarvis (2018)Case Study For Assessing The Abdomen Assignment, subjective data includes feelings, concerns, and patient perception. Regarding the case scenario, the patient’s chief complaint is generalized abdominal pain. Consequently, there is a need to have additional information on whether the pain has been gradual onset or sudden, including the activity that the patient had been doing before the pain started, which helps the clinicians narrow down the complaints to an actual diagnosis. The additional information that is needed for the case include requesting the patient to rate the pain on a 0-10 scale to help the clinician understand the pain intensity. Also, there is a need to assess if the pain is migratory or localized since the only information that the patient provides is that the pain radiates at the back but does not indicate the pain origin.

Additional Objective Data

The objective data is derived from the physical examination, including physical examination findings, vital signs, and laboratory results (Jarvis, 2018). In the given scenario, the patient objective data vital signs, including the patient’s temperature, blood pressure, and heart, lungs, and skin assessments. However, there is a need to add factors like general appearance such as patient mental status, sick-looking, nutritional status, severe pain, and gait. The main reason for that is that patients with conditions like pancreatic cancer tend to exhibit characteristics like malnourishment and cachexia symptoms. Since such characteristics may be found in pancreatic cancer patients, there will also be a need to add skin pigmentation, pallor, and jaundice information (Harding, 2019)Case Study For Assessing The Abdomen Assignment.

Jaundice assessment may help identify distended palpable gallbladder that may be identified through acholic stool, skin excoriation, and urine darkening. Also, there will be a need to add palpation, percussion, auscultation and inspection of the abdomen. There will also be a need for the inspection to identify abdominal distention. Also, assessing if the patient has scars in the abdomen is essential since it can help the clinician identify if the patient has had previous surgeries.

Objective and Subjective Information Support on the Assessment

The assessment of the patient concerns, Abdominal Aortic Aneurysm (AAA), perforated ulcer, and pancreatitis. The objective data support the assessment since the CT scan indicates that the patient’s abdomen is tender within the epigastric area, which signals the presence of AAA. The subjective data supports the perforated ulcer and pancreatic conditions, which assert that the patient has had since perforated ulcer has symptoms like vomiting and sudden pain with the pancreatic condition is ascertained by the patient pain that has lasted for the past two days and vomiting instance. However, the assessment is discredited since essential assessments needed to be part of the SOAP note are omitted. According to Jarvis (2018)Case Study For Assessing The Abdomen Assignment, the main area that clinical examination should involve include results, lab tests, differential diagnosis, diagnostics, and current co-morbidities. Concurrently, there would be a need to incorporate differential diagnosis information by pointing out the most probable diagnosis to the least since it would help make rational and informed decisions. Hence, the assessment part does not provide comprehensive information as it is needed to unify the objective and subjective proof in making the right decision.

Appropriate Diagnostic Test

Detection of the patient’s condition at an early stage will be essential since it will help prevent adverse effects and manage the condition effectively. Generally, physical examination, patient’s history, lab results, and radiography are vital when assessing abdominal pains. Due to the patient complaining of abdominal pain, Ultrasound and Computed Tomography Angiography (CTA) have been conducted, which are essential in ensuring that the clinician focuses on the coronary arteries to assess blockage. However, a basic metabolic panel (BMP) will also need to be assessed. The main reason for carrying out a BMP is to provide the clinician with an accurate image of the patient’s electrolyte status, considering that the patient has been vomiting, thus causing dehydration. Also, considering the patient has had hyperlipidemia, the clinician needs to carry out a lipid panel blood test to determine the patient’s cholesterol levels Case Study For Assessing The Abdomen Assignment.

Differential Diagnosis

Abdominal Aortic Aneurysm (AAA): Evidence Accepting

The abdominal aortic aneurysm (AAA) is life-threatening, especially when it bursts. Mainly, the condition is prevalent in smokers and older men. According to Sharma et al. (2021), some people notice AAA after experiencing a pulsating feeling around the navel. The main symptoms that patients with AAA exhibit include back and stomach pain acting as signs of impending rapture, all of which the scenario case study patient exhibits. From the patient history, he had been smoking for approximately 20 years but ended up quitting the last two years. Therefore, through the CTA scan, the clinician may identify the size of aneurysms to determine the most effective management procedure since if they are too large, surgery will be needed.

Perforation Ulcer: Evidence Rejecting

Perforation ulcer is a rare stomach ulcer complication in which the stomach lining splits open. The main causes are smoking and consumption of highly acidic beverages and foods. The main characteristics that the condition exhibits include sharp, severe, and sudden abdominal pain (Sharma et al., 2021). However, when reflecting on the patient’s case, the pain is severe, but there is no indication of whether the pain is sudden, while the pain is mainly at the back.

Pancreatitis: Evidence Rejecting

Pancreatitis occurs due to pancreas inflammation, and it mainly starts suddenly, though it lasts for days. The main symptoms include vomiting and upper abdominal pain (Sharma et al., 2021)Case Study For Assessing The Abdomen Assignment. However, in the case scenario patient complains of back pain despite experiencing vomiting symptoms.

Conclusion

The paper addressed additional subjective and objective data of the case scenario patient and the support this information has on the assessment, appropriate diagnosis, and differential diagnosis.

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References

Harding, M. M. (2019). Assessment: Integumentary System. Lewis’s Medical-Surgical Nursing E-Book: Assessment and Management of Clinical Problems, Single Volume, 395.

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.

Sharma, D., Meena, S., & Anand, G. (2021). Case Discussion in Surgery Acute Abdomen—Case Based Approach For Clinicians. J Indian Med Assoc, 119(3), 50-3. https://onlinejima.com/journals_doc/download-journals/2021/march/50-53.pdf Case Study For Assessing The Abdomen Assignment