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Case Study For Assessing The Abdomen Essay Paper

Case Study For Assessing The Abdomen Essay Paper

This paper discusses a case study of a man who presented to the emergency room with severe midepigastric abdominal pain. The man was diagnosed with AAA; however, as a precaution, a CT scan was ordered to rule out other potential causes of the pain. Further history or medical records were provided, and thus, diagnostic tests would be conducted based on such information to determine what the man was suffering from Case Study For Assessing The Abdomen Essay Paper

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Subjective Data

The subjective portion of the note based on the case provided is that the male had significant abdominal pain, diarrhea, and nausea. Apart from the abdominal pain, other information that should be included in documentation is that the man had a history of diabetes and hypertension and was also on medication for upper DI bleeding (UGIB) in the past four years. It would be appropriate for a healthcare provider to ask the patient to rate the severity of the pain on a scale of 0-10 as well as describe the pain in terms of sharpness, dullness, or whether it is causing a burning sensation. Further, the patient needs to be asked where the pain is originating, whether it is decreasing or increasing in severity, and whether it is radiating or not. The healthcare provider needs to ask about the main cause of the pain and what relieves it. Understanding the onset, site, aggravating factors, timing, and relieving factors helps the health providers narrow the diagnostic tests to those most probable based on the information presented by the client (Ramar et al., 2020)Case Study For Assessing The Abdomen Essay Paper. Since the pain is associated with diarrhea, it is also essential to understand how many episodes of diarrhea the patient experience a day, its contents, smell, the associating symptoms, the aggravating factors, and the relieving factors. Finally, the clinician should exhaust the signs and symptoms of other gastrointestinal system infections such as reflux, weight loss, nausea, loss of appetite, heartburn, and vomiting.

Objective Data

The essential signs in the soap note include Height of 5’10, Weight-248lbs (BMI-33.8 obese), Blood Pressure 160/86mmHg, RR-16, and Temperature99.8. After doing the above general examinations, the clinician needs to note if the patient looks sick or is in fair general health condition. Further, there is a need to examine whether the patient has dehydration, pallor, cyanosis, lymphadenopathy, and jaundice. According to Padhy et al. (2017)Case Study For Assessing The Abdomen Essay Paper, patients suffering from pancreatic cancer are pale, emaciated, and pale. Finally, the clinician should do percussion, inspection, palpation, and auscultation as part of the abdominal examination. On percussion, the clinician should note different abdominal quadrants such as dullness, tympanic note, and the percuss for shifting dullness. There is also a need for deep palpation to examine organ enlargement as well as tenderness in the lower quadrant.

Assessment

The assessment is supported by both subjective and objective information. The patient is experiencing severe abdominal pain and gastroenteritis. Additionally, the patient is having diarrhea, nausea and reports no history of vomiting. According to the study by Moffat et al. (2019), whenever the pancreas cannot produce pancreatic juice containing enzymes used in food digestion, it leads to indigestion that causes diarrhea. Further, any pain in the low part of the abdomen causes pain to other surrounding organs like the ureter, ileum, colon, and rectum, and since the patient had reported pain in the lower quadrant, then the pain in the lower abdomen may be due to gastroenteritis. The assessments presented above of abnormal abdominal findings can help nurses to better diagnose conditions in the abdomen (Yang et al., 2018)Case Study For Assessing The Abdomen Essay Paper. This will help to reduce the time and effort needed to make a correct diagnosis.

Diagnostic Tests

Diagnostic tests are essential in ruling out other potential causes of abdominal pain. These tests help identify the source of the pain and may include a liver function test, a full hemogram, and a tumor markers test. The full hemogram would rule out pancreatic cancer, thrombocytosis, anemia, or any other chronic illness (Giambelluca et al., 2019). The liver function test will examine whether there are increased levels of liver enzymes, which may be leading to jaundice. It will also be advisable for the clinician to do a tumor markers test to rule out pancreatic cancer. Lastly, the recommended test, the CT scan, will be imaged in the lower pelvic to determine the real cause of the pain.

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Potential Differential Diagnosis

I would accept the current diagnosis of AAA. The patient had severe midepigastric gradual abdominal pain, jaundice, vomiting, weight loss, and loss of appetite, which are common symptoms of AAA. Additionally, the doctor ordered a CT scan, which can help to confirm the diagnosis. According to Thapar et al. (2020), several possible conditions may be considered a differential diagnosis for this patient. These include intestinal ischemia, gastric lymphoma, pancreatic lymphoma, and abdominal aortic aneurysm. Each of these conditions can cause midepigastric abdominal pain, and each has a different treatment plan (Thapar et al., 2020)Case Study For Assessing The Abdomen Essay Paper. Upon examination, the left lower quadrant was tender, which is why the author accepted the current diagnosis.

References

Giambelluca, D., Cannella, R., Caruana, G., Salvaggio, L., Grassedonio, E., Galia, M., … & Salvaggio, G. (2019). CT imaging findings of epiploic appendagitis: an unusual cause of abdominal pain. Insights into imaging, 10(1), 1-9.

Ramar, P., Roellinger, D. L., Merrick, R. F., Ebbert, J. O., & Philpot, L. M. (2020). Helpfulness of Clinical Visit Summary Content From Multi-Specialty Care: A Mixed-Methods Assessment. Health services research and managerial epidemiology, 7, 2333392820950909.

Thapar, N., Benninga, M. A., Crowell, M. D., Di Lorenzo, C., Mack, I., Nurko, S. & Enck, P. (2020). Pediatric functional abdominal pain disorders. Nature reviews Disease primers, 6(1), 1-23.

Yang, S., Dong, K., & Zheng, S. (2018). Abdominal pain as the presenting symptom of Takayasu arteritis in an adolescent male: a case report. Medicine, 97(26).

Padhy, B., Murmu, D., Samal, D., & Jha, S. (2017). Clinical study of surgical jaundice: an institutional experience. International Surgery Journal, 5(1), 138-142.

Moffat, G. T., Epstein, A. S., & O’Reilly, E. M. (2019). Pancreatic cancer—A disease in need: Optimizing and integrating supportive care. Cancer, 125(22), 3927-3935.

This paper discusses a case study of a man who presented to the emergency room with severe midepigastric abdominal pain. The man was diagnosed with AAA; however, as a precaution, a CTA scan was ordered to rule out other potential causes of the pain. There was no further history or medical records provided, and thus, to determine what the man was suffering from, diagnostic tests would be conducted. Case Study For Assessing The Abdomen Essay Paper

Subjective Data

The subjective portion of the note based on the case provided is that the male had significant abdominal pain and was diagnosed with AAA. Apart from the abdominal pain, other information that should be included in documentation is the patient’s age, sex, and medical history. In addition, other conditions that could mimic AAA, such as pancreatitis or diverticulitis, should also be noted. It is important to document any discrepancies between the two sets of information. The CTA scan provides detailed images of the abdomen that reveal any abnormalities or differences from the subjective portion of the note (Thapar et al., 2020). The findings on the CTA scan include a mass in the right side of the abdomen, which is consistent with AAA. The mass in the right side of the abdomen is larger than what was reported in the subjective portion of the note and suggests that a more severe condition may present. The CTA scan also reveals several other abdominal abnormalities, such as an enlarged liver and intestines, which could indicate pancreatitis or diverticulitis. Therefore, the findings on the CTA suggest that the male has significant abdominal pain and was diagnosed with AAA.

Objective Data

The objective portion of the note states that the patient had severe midepigastric abdominal pain and was diagnosed with AAA. Additional information that should be included in the documentation includes a description of the patient’s symptoms, the results of the medical test, and any further treatment that was provided. The description of the patient’s symptoms will aid in determining the cause of the abdominal pain (Giambelluca et al., 2019)Case Study For Assessing The Abdomen Essay Paper. The medical test results will help identify any abnormalities in the patient’s abdomen and may lead to a more accurate diagnosis. Additionally, a summary of the patient’s overall health should be included in the documentation. According to Ramar et al. (2020), a summary of the patient’s overall health will help to ensure that all pertinent information is captured and that the correct treatment is provided.

Assessment

The assessment is supported by both subjective and objective information. The patient is experiencing severe abdominal pain, and the CTA scan shows an AAA. This is consistent with the diagnosis of AAA. However, the patient may also have other conditions that are causing his abdominal pain. By analyzing case studies of abnormal abdominal findings, nurses can better diagnose conditions in the abdomen (Yang et al., 2018). This will help to reduce the time and effort needed to make a correct diagnosis. However, the assessment is not completely supported by subjective information. The patient did not mention experiencing other symptoms before going to the emergency room. This suggests that the patient’s abdominal pain may be unrelated to AAA.

Diagnostic Tests

Diagnostic tests are essential in ruling out other potential causes of abdominal pain. These tests help identify the source of the pain and may include an x-ray of the abdomen, blood test, an ultrasound, or a CTA scan. The first diagnostic test that will be conducted is the x-ray of the abdomen. This diagnostic test will help rule out any structural abnormalities in the abdomen, such as a hernia or tumor. If the source of abdominal pain is not determined, a blood test may be necessary. The blood test will help to determine the levels of certain enzymes in the blood, which can help to identify a type of liver or pancreatic cancer (Yang et al., 2018). If both diagnostic tests do not reveal any significant findings, a CTA scan will be conducted. The CTA scan would be most appropriate because it can show a more detailed imaging technique that can help to determine the source of abdominal pain (Thapar et al., 2020)Case Study For Assessing The Abdomen Essay Paper. This test will help to identify any tissue abnormalities in the abdomen, such as a tumor or hernia. The results of these tests will be used to make a more definitive diagnosis of the cause of abdominal pain.

Potential Differential Diagnosis

I would accept the current diagnosis of AAA. The patient had severe midepigastric abdominal pain, which is a common symptom of AAA. Additionally, the doctor ordered a CTA scan, which can help to confirm the diagnosis. According to Thapar et al. (2020), several possible conditions may be considered a differential diagnosis for this patient. These include pancreatitis, gallbladder disease, and aortic aneurysm. Each of these conditions can cause midepigastric abdominal pain, and each has a different treatment plan (Thapar et al., 2020)Case Study For Assessing The Abdomen Essay Paper. I would recommend that the patient be evaluated for each of these conditions based on the symptoms that he is experiencing.

References

Giambelluca, D., Cannella, R., Caruana, G., Salvaggio, L., Grassedonio, E., Galia, M., … & Salvaggio, G. (2019). CT imaging findings of epiploic appendagitis: an unusual cause of abdominal pain. Insights into imaging, 10(1), 1-9.

Ramar, P., Roellinger, D. L., Merrick, R. F., Ebbert, J. O., & Philpot, L. M. (2020). Helpfulness of Clinical Visit Summary Content From Multi-Specialty Care: A Mixed-Methods Assessment. Health services research and managerial epidemiology, 7, 2333392820950909.

Thapar, N., Benninga, M. A., Crowell, M. D., Di Lorenzo, C., Mack, I., Nurko, S. & Enck, P. (2020). Pediatric functional abdominal pain disorders. Nature reviews Disease primers, 6(1), 1-23.

Yang, S., Dong, K., & Zheng, S. (2018). Abdominal pain as the presenting symptom of Takayasu arteritis in an adolescent male: a case report. Medicine, 97(26).

You have a case assignment this week that is  NOT a soap note.  This is a paper.

The Assignment 

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)Case Study For Assessing The Abdomen Essay Paper

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

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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.

  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 Case Study For Assessing The Abdomen Essay Paper