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)  Abdominal Assessment Example 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
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.
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
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.  Abdominal Assessment Example Paper

Abdominal Assessment

Subjective Portion Analysis

The information presented in the subjective section is inadequate and cannot adequately direct a diagnosis. Subjective data should, as a general rule, be as comprehensive as possible since doing so assists in the diagnostic process. The current health status does not provide all of the details that would be necessary to comprehend the illness from the way it is laid out. The following is a list of additional information that ought to be included in the subjective data:

• The characteristics of pain
• What provides relief from the pain
• What makes the pain worse
• Pain radiation to other body parts
• How many times a day the symptoms manifest themselves
• The texture of the stool
• The patient’s usual diet as well as the foods that were consumed just before the beginning of symptoms
• How medications are taken, and how often they are taken.
• Immunization records

Objective Portion Analysis

The term “objective data” refers to information that can be assessed by means such as a physical examination, observation, or diagnostic testing. The physical observations or patient characteristics that the nurse observes, the results of laboratory tests, and vital signs are some examples of objective data. Additional objective information that should be included in the note includes:

• Constitutional data
• Information about the abdominal status, such as bowel sounds
• Guarding pain location.
• Electrolyte imbalance
• Inspection of skin
• BMI
  

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Assessment

As per the patient’s assessment of his level of discomfort on a scale from one to ten, the data provided, both subjective and objective, lends credence to the possibility that the patient is suffering from pain in the left lower quadrant. However, gastroenteritis does not seem to be supported by either subjective or objective evidence at this time. It is necessary for the practitioner to investigate additional illnesses that might be diagnosed with the same clinical presentation, like indigestion, gastritis, food poisoning, and appendicitis, until diagnostic procedures can substantiate this diagnosis. In most cases, vomiting is the first symptom of gastroenteritis. The patient complained of feeling nauseous but did not mention having any vomiting episodes. To assist in the formulation of an accurate diagnosis, it is essential to conduct additional questioning about the patient’s history of encounter with a variety of foods, as well as their method of food handling and preparation.

Diagnostic Tests

Laboratory examinations and imaging techniques, such as radiography, are both examples of diagnostic procedures that can be used in this case. According to the patient’s medical history, he has had problems in the past with gastrointestinal bleeding. A stool culture, complete blood count, and a computed tomography scan are the necessary diagnostic tests that should be performed on the patient. A complete blood count (CBC) may identify infections, anemia, and even leukemia, in addition to determining how much blood a patient with gastrointestinal bleeding has lost (Nemeth & Pfleghaar, 2021). The color of the stool, as well as whether or not it contains blood, may be determined with the use of a stool culture. Additionally, it will detect the norovirus or rotavirus virus, both of which may trigger acute gastroenteritis, which can lead to bleeding. The CT testing will determine the underlying reason for the stomach pain. It is able to identify anomalies in the small intestines as well as in other organs inside the body (Frickenstein et al., 2019). In addition, it can be used to screen for colorectal cancer. The results of all of these diagnostic tests together will contribute to a more accurate diagnosis. Abdominal Assessment Example Paper

Differential Diagnoses

I accept the left lower quadrant pain as a possible diagnosis based on the patient’s assessment of his level of pain. On the other hand, I do not believe that the patient is suffering from gastroenteritis since the information that has been presented to me does not support this possibility. Irritable bowel syndrome, diverticulitis, and Shigella infection are the three potential illnesses that could be considered a differential diagnosis for this particular patient.

Because the patient is experiencing diarrhea and abdominal discomfort, it is important to evaluate the possibility that they have an infection caused by shigella. The patient has had the symptoms for a three-day period. The most prominent symptom of shigella infection is diarrhea, which often contains blood (Baker & The, 2018). The patient is experiencing diarrhea, which is why it is essential to assess his stool to determine whether or not he has a shigella infection. Considering diverticulitis most often occurs in the left colon, which is exactly where the patient’s symptoms are presenting, a diagnosis of diverticulitis should be evaluated. While the etiology of diverticulitis is unknown, obesity is claimed to be one of the variables that might lead to the condition (Turner et al., 2020). This applies to this patient, who has a body mass index of 35.6. Irritable bowel syndrome is another ailment of the gastrointestinal system that should be considered a differential diagnosis since it has many of the same symptoms as the patient’s current condition. It is also the most prevalent disorder of the gastrointestinal tract (Patel & Shackelford, 2018).

References

Baker, S., & The, H. C. (2018). Recent insights into shigella. Current Opinion in Infectious Diseases, 31(5), 449-454.  https://doi.org/10.1097/qco.0000000000000475

Frickenstein, A. N., Jones, M. A., Behkam, B., & McNally, L. R. (2019). Imaging inflammation and infection in the gastrointestinal tract. International Journal of Molecular Sciences, 21(1), 243. https://doi.org/10.3390/ijms21010243

Nemeth, V., & Pfleghaar, N. (2021). Diarrhea. https://www.ncbi.nlm.nih.gov/books/NBK448082/

Patel, N., & Shackelford, K. S. (2018). Irritable Syndrome Syndrome.  https://europepmc.org/article/med/30521231

Turner, G. A., O’Grady, M., Frizelle, F. A., Eglinton, T. W., & Sharma, P. V. (2020). Influence of obesity on the risk of recurrent acute diverticulitis. ANZ Journal of Surgery, 90(10), 2032-2035.  https://doi.org/10.1111/ans.15784

Abdominal Assessment Example Paper