LAB ASSIGNMENT: ASSESSING THE ABDOMEN

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

THE ASSIGNMENT
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

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: Denies weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: Denies rash or itching.

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

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

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

MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

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

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

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

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting.

ORDER A CUSTOM-WRITTEN PAPER HERE

Lab Assignment: Assessing the Abdomen

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint): “My stomach has been nursing for the last few days.”

HPI: LZ is a 65-year-old male who visited the emergency department with a history of intermittent epigastric abdominal pain that radiates to his back. He took some PPIs that had no significant effect in relieving the patient. The patient reports that the pain has increased in severity for the last few hours. Over lunch, he vomited, which led him to the emergency department. Besides, he claims to have no fever, diarrhoea, or symptoms associated with abdominal pain.

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd, Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both two years ago, divorced for five years, three children, two males, one female

Additional Information Required

There needs to be additional information as part of the subjective history-taking process. The information should include the present pain level, duration, location of the discomfort, and associated symptoms. At the same time, the information on how the patient responded to past medication should be included. Mainly, this will help determine the patient’s next course of action. Any information that will help make the right and accurate decision should be obtained. Likely, the patient may not accurately describe everything they have felt, seen, or done. The providers will want to know the issue, the duration of symptoms, and where they feel uncomfortable, among other relatable symptoms. Information can be obtained through physical examination, history-taking, and other observations. The data can be determined or acquired by asking each question about each body part. A review of systems (ROS) is needed to understand the patient’s condition better. The following is a sample of ROS that can be obtained from the patient:

Example of Complete ROS:

GENERAL: Should include information on weight loss, fever, chills, weakness, or fatigue.

HEENT: Should include information on head, ears, eyes, nose, and throat.

SKIN: Should include whether there are any rash or itchiness

CARDIOVASCULAR: Should consist of information on chest pain

RESPIRATORY: contains elements such as shortness of breath, cough, or sputum

GASTROINTESTINAL: Should consist of any abdominal-related problem. In this case, the patient claims to have abdominal pain that radiates to the back.

GENITOURINARY: should include whether there is burning on urination.

NEUROLOGICAL: Should consist of dizziness elements and other neurological conditions

MUSCULOSKELETAL: provides information on muscle and back pain

HEMATOLOGIC: Should consist of any anemic or bruising conditions

LYMPHATICS: Focuses on enlarged nodes

PSYCHIATRIC: Suitable to determine the patient’s mental state

ENDOCRINOLOGIC: Includes reports on sweating, chills, or cold

ALLERGIES: Include any history of asthma or rhinitis

Objective

Physical Exam: Vital Signs: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs

Heart: RRR, no murmurs

Lungs: CTA, chest wall symmetrical

Skin: Intact without lesions, no urticaria

Abdomen: The abdomen is tender in the epigastric area with guarding but without mass or rebound.

Diagnostics: US and CTA

Additional Objective Information Required

The objective section is a critical element of patient evaluation. It has to be comprehensive as it informs the diagnostic tests to be conducted on the patient. One essential remark missing from the objective section concerns the patient’s pain and acuity levels. The location of the pain should be adequately evaluated. The vital signs have been well provided and form part of the findings. When assessing a patient with abdominal pain, information about their genitourinary is needed since any issues such as urinary infection or kidney diseases can manifest in the form of abdominal pain. Such information is required to avoid a situation of misdiagnosis of the patient.

Differential Diagnoses:

Abdominal Aortic Aneurysm (AAA): AAA is a primary concern since the patient has mid-epigastric abdominal pain. The enlargement of the abdominal aorta characterizes the condition and can be life-threatening when it ruptures (Lattanzi, 2020). The risk factors for the disease are male, old age, and history of vascular ailments. The condition can be tested and confirmed through ultrasound and CTA.

Perforated ulcers: The condition is characterized by ulcers in the gastrointestinal tract that have eroded through the wall, hence causing a leakage of stomach content to the abdominal cavity (Ali et al., 2022). The symptoms include abdominal pain, and there could be signs of tenderness in the stomach. The condition can be tested through abdominal imaging.

Pancreatitis: This condition is characterized by pancreas inflammation and could lead to severe abdominal pain (Chatila et al., 2019). The symptoms include upper abdominal pain that can be severe and may radiate to the back. The condition worsens with increased alcohol consumption, gallstones, and certain medications. The pancreatic enzyme levels in blood tests and imaging can help evaluate the extent of complications and inflammations.

Does Subjective and Objective Information support Assessment?

The judgment on AAA as a primary diagnosis is backed by subjective and objective information. The patient has stomach pain that has been growing in severity. The physical exam reveals the patient’s abdomen is sensitive in the epigastric area. However, there is no mass or rebound discomfort, a common sign and symptom of abdominal aortic aneurysm.

Diagnostic Tests

Based on the information provided, a CT scan or an ultrasound would be recommended to assess the patient’s abdomen. The imaging results would help rule out or confirm the diagnosis of AAA or any other illnesses. A CT scan would help provide critical information on the patient’s abdominal organs. In contrast, the ultrasound would help determine if there are any inflammation or abnormalities in the overall bowel functioning.

Further, CTA (Computed Tomography Angiography) is needed to confirm the presence of AAA and determine its size while evaluating the risk of rupture. A complete blood count is required to check for any infection or anemia. Also, a basic metabolic panel would be needed to evaluate the electrolyte levels in the blood and determine the patient’s renal function to rule out kidney diseases.

Acceptance/ Rejection of Current Diagnosis

The AAA diagnosis can be acknowledged. This is mainly because AAA often presents as epigastric abdominal pain that radiates to the back, and incidences of nausea and vomiting are also prevalent (Lattanzi, 2020). However, the differential diagnoses for the patient may include perforated ulcer, pancreatitis, and appendicitis. A perforated ulcer is a hole in the stomach lining that allows digestive juices and food to move to the stomach’s cavity walls. At the same time, pancreatitis is characterized by inflammation of the pancreas. Appendicitis occurs when the appendix is inflamed and can cause stomach pain, nausea, vomiting, and fever (Krzyzak & Mulrooney, 2020). The probable conditions should be subject to investigation for further evaluation.

References

Ali, A. M., Mohamed, A. N., Mohamed, Y. G., & Keleşoğlu, S. İ. (2022). Clinical presentation and surgical management of perforated peptic ulcer in a tertiary hospital in Mogadishu, Somalia: A 5-year retrospective study. World Journal of Emergency Surgery, 17(1). https://doi.org/10.1186/s13017-022-00428-w

Chatila, A. T., Bilal, M., & Guturu, P. (2019). Evaluation and management of acute pancreatitis. World Journal of Clinical Cases, 7(9), 1006-1020. https://doi.org/10.12998/wjcc.v7.i9.1006

Krzyzak, M., & Mulrooney, S. (2020). Acute appendicitis review: Background, epidemiology, diagnosis, and treatment. Cureus. https://doi.org/10.7759/cureus.8562

Lattanzi, S. (2020). Abdominal aortic aneurysms: Pathophysiology and clinical issues. Journal of Internal Medicine, 288(3), 376-378. https://doi.org/10.1111/joim.13060