Case Study For Generalized Abdominal Pain Discussion

Case Study For Generalized Abdominal Pain Discussion

Week 6
Posted on: Sunday, July 3, 2022 8:31:38 AM EDT

Hello Class,

Welcome to week 6! We have lots to do this week. 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

ORDER A PLAGIARISM-FREE PAPER HERE

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: Case Study For Generalized Abdominal Pain Discussion

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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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 three different references from current evidence-based literature. Case Study For Generalized Abdominal Pain Discussion
By Day 7 of Week 6

oto Credit: Getty Images/Hero Images

A male went to the emergency room for severe midepigastric 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:
Review this week’s Learning Resources, and 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.
The Assignment Case Study For Generalized Abdominal Pain Discussion
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 three different references from current evidence-based literature.
By Day 7 of Week 6
Submit your Lab Assignment.

Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK6Assgn1+last name+first initial.(extension)” as the name.
Click the Week 6 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
Click the Week 6 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK6Assgn1+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission. Case Study For Generalized Abdominal Pain Discussion

ORDER HERE

Week 6: Abdominal Assessment

Subjective Portion Analysis

Subjective data is health-related information shared by the client during the clinical interview. In the provided scenario, the client, JR, is a 47yo female who presented to the clinic with general abdominal pains that started in the past three days. The client added experiencing diarrhea, and nothing relieved it. She denies taking any medication, claiming she was unsure what to take. She rates her pain during the clinical interview as 5/10. She reports that the pain was less severe than when it started (9/10). The client further reports experiencing nausea after taking her meals.

However, additional information should be collected to develop a comprehensive patient’s health history. First, in addition to the intensity of the pain, the client should share other details about the pain, including the location, quality, aggravating and relieving factors, and if the pain is radiating. The client should also indicate if the pain started suddenly or has developed gradually and if she was working or resting when the pain started. Furthermore, the client should give more details concerning diarrhea, such as the frequency of bowel movements. According to August and Sibai (2017)Case Study For Generalized Abdominal Pain Discussion, patients should provide details of presented clinical manifestations to enable the healthcare provider to determine the severity of the patient’s condition and rule out the probable diagnosis. Therefore, providing all aspects of the pain will help the medical professional to make an appropriate diagnosis and rule out possible illnesses.

Objective Portion Analysis

            The client reported generalized abdominal pain and diarrhea, necessitating a detailed abdominal and physical examination. For this reason, the healthcare provider should include details regarding the patient’s appearance, including appearances such as seek-looking, mental distress, grooming, behavior during the clinical interview, and nutritional status. Furthermore, the healthcare provider should record details obtained following the abdomen’s inspection, palpation, percussion, and auscultation. The clinician should include details of abdominal distension after inspecting the abdomen. This information is helpful in ruling out probable causes such as pancreatic cancer, mainly characterized by painful abdominal distension (Coveler et al., 2021)Case Study For Generalized Abdominal Pain Discussion. The healthcare provider should also include details regarding the presence or absence of a scar, which indicates previous surgery. Additionally, the medical professional should consist more information about visible distended veins after examining the abdomen. More so, the clinician should capture details of the abdomen such as being soft, fluid-filled, rigid, tender, or non-tender guarding after palpation. Abdomen rigidity mainly indicates the presence of digestive juices or blood in the peritoneal cavity. Therefore, the additional objective data helps narrow down the probable diagnosis.

The Connection between the Assessment and the Subjective and Objective Information

In addition to subjective and objective data, the results of diagnostic tests would guide a healthcare provider in making an appropriate diagnosis for this client. First, the healthcare professional should order abdominal radiography. The results of this diagnostic test will be used to establish the cause of the unexplained abdominal pain. Secondly, a complete blood count (CBC) is recommended for this client to detect an infection. According to Natesan and Werley (2021), CBD should be performed to detect disease in a patient with abdominal pain. The healthcare provider can relate the presence of an infection in the body to the reported abdominal pain. Furthermore, liver enzymes/hepatic function tests should be conducted to assess the functioning of the liver and if the liver is eliminating adequate harmful toxins from the body. If results indicate improper liver functioning, the reported abdominal pain can be associated with a condition affecting the liver. Lastly, urinalysis should be conducted to assess the presence of an infection or blood in the urinary tract, which could be a potential cause of the reported abdominal pain.

Rejecting/Accepting the Current Diagnosis

            The client’s current diagnosis is gastroenteritis. This condition is characterized by various clinical manifestations, including non-bloody and watery diarrhea, nausea and vomiting, stomach pain and aches, occasional headache or muscle aches, and low-grade fever (Barrett & Fhogartaigh, 2017). The client reported abdominal pain and diarrhea; hence she qualifies for gastroenteritis as the primary diagnosis. Nonetheless, three potential differential diagnoses should be considered to rule out probable disorders for this patient. The first differential diagnosis for this client is inflammatory bowel disease, characterized by diarrhea, cramping and abdominal pain, fatigue, blood in the stool, decreased appetite, and unintended weight loss. The client might have this disorder since she reported abdominal pain and diarrhea. However, this condition is ruled out due to the absence of significant symptoms, including fatigue, blood in the stool, decreased appetite, and unintended weight loss. Secondly, the client can be diagnosed with appendicitis, characterized by sudden pain in the lower abdomen, starts around the navel, shifts to the lower right abdomen, and worsens while walking. The client qualifies for this condition since she reported abdominal pain. Nonetheless, this condition is ruled out since the client did not report significant aspects of appendicitis-related pain, including beginning suddenly around the navel and shifting to the lower abdomen. Lastly, food poisoning is characterized by nausea, cramping, vomiting, or diarrhea. The client qualifies for this diagnosis since she reports abdominal pain and diarrhea. However, this condition is ruled out due to the absence of nausea and vomiting Case Study For Generalized Abdominal Pain Discussion.

Overall, the client presented with abdominal pain and diarrhea. Based on subjective data and physical examination, she was diagnosed with gastroenteritis, which is characterized by various clinical manifestations, including non-bloody and watery diarrhea, nausea and vomiting, stomach pain and aches, and occasional headache or muscle aches, and low-grade fever. Therefore, the current diagnosis is supported by subjective and objective data. However, diagnostics, including abdominal radiography, CBC, liver enzymes/hepatic function test, and urinalysis, should be performed to ensure an appropriate diagnosis. Additionally, differential diagnoses, including inflammatory bowel disease, appendicitis, and food poisoning, should be conducted to rule out these conditions, which are characterized by the reported symptoms.

References

August, P., & Sibai, B. M. (2017). Preeclampsia: Clinical features and diagnosis. Post TW, UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/preeclampsia-clinical-features-and-diagnosis

ORDER TODAY

Barrett, J., & Fhogartaigh, C. N. (2017). Bacterial gastroenteritis. Medicine, 45(11), 683-689. DOI: 10.32474/CTGH.2019.02.000147

Coveler, A. L., Mizrahi, J., Eastman, B., Apisarnthanarax, S. J., Dalal, S., McNearney, T., & Pant, S. (2021). Pancreas cancer-associated pain management. The oncologist, 26(6), e971-e982. https://doi.org/10.1002/onco.13796

Natesan, S., & Werley, E. B. (2021). Laboratory Tests in the Patient with Abdominal Pain. Emergency Medicine Clinics, 39(4), 733-744. Doi: 10.1016/j.emc.2021.08.001. Epub 2021 Sep 9 Case Study For Generalized Abdominal Pain Discussion