Week 6: Assessment of the Abdomen and Gastrointestinal System

On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?

Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.  Assessing the Abdomen and Gastrointestinal System Essay Example

This week, you will explore how to assess the abdomen and gastrointestinal system.

Learning Objectives – Week 6: Assessment of the Abdomen and Gastrointestinal System
Students will:
Evaluate abnormal abdomen and gastrointestinal findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system

Learning Resources – Week 6: Assessment of the Abdomen and Gastrointestinal System
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

Chapter 17, “Abdomen” (pp. 370-415)In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment on the abdomen.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 3, “Abdominal Pain” (pp. 11-32)This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.
Chapter 10, “Constipation” (pp. 110-117)The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.
Chapter 12, “Diarrhea” (pp. 133-147)In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.
Chapter 29, “Rectal Pain, Itching, and Bleeding” (pp. 344-356)This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 10, “Admitting a Patient to the Hospital” (pp. 217-238)
Note: Download this Adult Examination Checklist and Abdomen Physical Exam Summary to use during your practice abdominal examination.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for abdominal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Adult Examination Checklist: Guide for Abdominal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Abdomen. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.

This Abdomen Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/

University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html. This website provides an introduction to radiology and imaging. For this week, focus on gastrointestinal radiology.

Required Media
Online media for Seidel’s Guide to Physical Examination

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It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7, and 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.

Optional Resources- Week 6: Assessment of the Abdomen and Gastrointestinal System
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)This chapter explores the health assessment processes for the abdomen, perineum, anus, and rectosigmoid. This chapter also examines the symptoms of many conditions in these areas.
Chapter 10, “The Urinary System” (pp. 528–540)In this chapter, the authors provide an overview of the physiology of the urinary system. The chapter also lists symptoms and conditions of the urinary system. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.
NURS 6512 Assesment 1: Assessing the Abdomen
A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.  Assessing the Abdomen and Gastrointestinal System Essay Example

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 assignment, you will analyze a SOAP 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.

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)
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, hyperctive bowel sounds, pos pain in the LLQ
Diagnostics: None
NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System
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.

To prepare:

With regard to the SOAP 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.
To complete:

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 3 different references from current evidence based literature.
By Day 7
This assignment is due.

Submission and Grading Information
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Name: NURS_6512_Week_6_Assignment1_Rubric
Excellent Good Fair Poor
Quality of Work Submitted:
The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking.
Points Range: 27 (27%) – 30 (30%)
Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics.
Points Range: 24 (24%) – 26 (26%)
Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.
Points Range: 21 (21%) – 23 (23%)
Assignment meets most of the expectations. One required topic is either not addressed or inadequately addressed.
Points Range: 0 (0%)– 20 (20%)
Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.
Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student’s ability to:Understand and interpret the assignment’s key concepts.
Points Range: 27 (27%) – 30 (30%)
Demonstrates the ability to critically appraise and intellectually explore key concepts.
Points Range: 24 (24%) – 26 (26%)
Demonstrates a clear understanding of key concepts.
Points Range: 21 (21%) – 23 (23%)
Shows some degree of understanding of key concepts.
Points Range: 0 (0%)– 20 (20%)
Shows a lack of understanding of key concepts, deviates from topics.
Assimilation and Synthesis of Ideas:
The extent to which the work reflects the student’s ability to:Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources.
NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System

Points Range: 18 (18%) – 20 (20%)
Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to support point of view.
Points Range: 16 (16%) – 17 (17%)
Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view.
Points Range: 14 (14%) – 15 (15%)
Minimally includes and integrates specific information from 2-3 resources to support major points and point of view.
Points Range: 0 (0%)– 13 (13%)
Includes and integrates specific information from 0 to 1 resource to support major points and point of view.
Written Expression and FormattingParagraph/Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate  of the time

Assessing the Abdomen and Gastrointestinal System: The Case Study of a 47 Year-Old Caucasian Male Presenting with Generalized Abdominal Pain

Proximity of abdominal organs is one of the reasons why correct diagnosis of pain of abdominal origin is difficult. There are many differential diagnoses that could all be true for the same expression of pain. It is even more tasking when it comes to deciding whether the pain is a result of pathophysiologic processes in the gastrointestinal tract (GIT) or the other organs in the lower abdomen like the kidneys or the uterus in females. Understanding of the anatomy and physiology of the abdomen coupled with meticulous and systematic history taking and physical examination is needed to make the correct diagnosis and differential diagnosis. While doing this, the concept of referred pain should be kept in mind (Ball et al., 2019; Bickley, 2017; LeBlond et al., 2014). In this case study, the patient (JR) is a 47 year-old Caucasian male who reports to the facility with generalized abdominal pain accompanied by diarrhea for three days. The pain fluctuates between severe (9/10) and moderate (5/10) and allows him to eat albeit with some nausea in the postprandial period. The patient has hypertension, diabetes, and a history of gastrointestinal bleeding four years ago. He currently takes amlodipine, lisinopril, metformin, and also injects Lantus insulin for his diabetes mellitus. He has no drug allergies that are known but has a family history of type II diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease or GERD. There is no family history of colon cancer. Patient JR is married with three children and only occasionally takes alcohol. He denies ever smoking. This paper provides the missing information in his SOAP note documentation presented in the case study. It also examines whether the subjective and objective information supports the given provisional diagnosis and presents three possible differential diagnoses for the patient.

Additional Information Missing from the Subjective Portion of the SOAP Documentation

There are missing elements in the HPI as dictated by the mnemonic POLDCARTS. The other missing subjective components are immunization history and a review of systems (ROS). On the HPI, information about the abdominal pain is provided in terms of location (abdomen), onset (3 days ago), and scale (5/10 to 9/10). The missing information that needs documentation is therefore as follows:

HPI: The patient denies having a previous history of this symptom and states that the pain is intermittent, lasting for about one minute per episode. It is however becoming more and more frequent. The pain is characteristically sharp and stabbing in nature and is aggravated by physical activity. It is slightly relieved by rest and meditation. The pain is there all day but becomes worse during the day when the patient is physically active.

Immunization History: The patient received all childhood immunizations as required. He got the pneumococcal vaccine in 2018, the influenza vaccine in 2019, and the last Tdp booster injection in March 2020.

Review of Systems (ROS)

General: Patient JR refuses having fatigue, weakness, fever, or weight loss.

HEENT: He is not suffering from migraine or any other type of headache. He denies excessive tearing of the eyes as well as double vision and photophobia. He also denies ear discharge, hearing loss, or tinnitus. He denies having a runny nose or nose bleeding. He is not sneezing. He denies difficulty in swallowing or a sore throat. His last visit to the ophthalmologist was in August 2020 and to the ENT specialist in June 2019. Assessing the Abdomen and Gastrointestinal System Essay Example

Gastrointestinal: He reports stomach pains that are generalized and accompanied by diffuse cramps. He reports having diarrhea and postprandial nausea. For three days now since the symptoms started showing, his bowel movements have increased in frequency with the last one being on the morning of coming to the clinic. He denies melena or hematochezia.

Cardiovascular: Patient JR denies having chest tightness or chest pains. He also denies tachycardia or any palpitations.

Integumentary (skin): He denies an itchy skin or rashes.

Respiratory: He is not coughing, produces no phlegm, and denies having any form of difficulty in breathing.

Genitourinary: He denies frequency of micturition, dysuria, low urine output, excessive urination per episode, or lack of urine. Patient JR is heterosexual in orientation. He is married to one wife and has three children – a girl and two boys.

Musculoskeletal: He does not have joint pains or muscle pains. He denies back pains.

Endocrinologic: He denies excessive sweating, excessive thirst, or excessive intake of water. He also denies heat intolerance or treatment with hormonal therapy.

Neurological: He denies disordered sensation in the extremities (pins and needles). He also denies loss of bladder and bowel control. He has not experienced unexplained fainting or loss of consciousness.

Hematologic: Patient JR denies a history of clotting or blood disorders. He denies bruising, dizziness, and syncope.

Psychiatric: He denies ever experiencing symptoms of depression or anxiety or ever receiving treatment for any psychiatric illness or disorder.

Lymphatics: He denies having swollen lymph glands or a surgical history of splenectomy.

Allergic/ Immunologic: he denies food and medication allergies. He is also not allergic to any environmental irritants such as smoke, pollen, and dust. He denies the allergy conditions of eczema, allergic rhinitis, hives, or asthma.

Additional Information to be Included in the Documentation of the Objective Portion of the SOAP Note

The documentation of the objective part of the SOAP Note is exhaustive save for two important components. These are the constitutional or general evaluation as well as assessment of the head, eyes, ears, nose, and throat (HEENT). The general assessment is the clinician’s general or global view of the patient as at a glance when they are entering the consultation room and during the interview. This missing objective information should have been included as follows:

Constitutional or General: Patient JR is well groomed and does not appear dishevelled. He does not have disturbed gait and the clothing is appropriate for the weather and time of the day. He is alert, concious, and oriented in time, place, space, person, and event. His speech is coherent and spontaneous. There are no obvious tics or mannerisms noted.

HEENT: Inspection of his head reveals that it is atraumatic and normocephalic. Examination of both pupils shows that they are both equal, round, and reactive to light and accommodation (PERRLA). There is no evidence of squint and all the extraoccular muscles and movements are intact. The sclerae are not yellow in color and there is no tearing. The eyes do not appear infected. Inspection of the ears reveals a clear external auditory canal. There is no impaction of cerumen bilaterally. The tympanic membranes are not perforated and there is no fluid level that can be demonstrated bilaterally. The nasal turbinates are not inflamed on inspection. The nasal septum is medially placed and there is no evident rhinorrhea. The oropharynx is not erythematous and no exudate can be demonstrated.

Support of the Assessment by the Subjective and Objective Information Documented

The subjective and objective information provided indeed supports the assessment of left lower quadrant pain and a provisional diagnosis of gastroenteritis. The rationale for this is in the patient’s own subjective chief complaint statement that they have abdominal pain and are having diarrhea with postprandial nausea. The HPI also gives more details about the kind of abdominal pain that patient JR is suffering from. According to Hammer and McPhee (2018), a diagnosis of gastroenteritis is usually made from a presentation of diarrhea, low-grade fever, abdominal cramps or pain, and nausea (Huether & McCance, 2017; Duncan, 2014). Patient JR meets all of these diagnostic criteria. He is having a fever of 99.8°F or 37.7°C. This means that the full diagnostic designation should be infectious gastroenteritis and colitis, whose ICD-10-CM code is A09. In all, therefore, the symptomatology presented and the knowledge of gastrointestinal anatomy and physiology both lead to the conclusion that the assessment of LLQ abdominal pain and GE is accurate.

Appropriate Diagnostic Tests for this Case

The documentation shown in this case study reveals that no diagnostics were performed for this patient. This is outside the norm, but there is a realization here that the patient could have been seen by a primary health care clinician in a resource-limited rural setting without the capability for performing diagnostics. In this case, the diagnostic tests that are appropriate and that could have assisted in making the correct diagnosis include the following:

1. A full blood count: Performing a complete blood count (CBC) in this case would be best practice. This is because the discovery of significant leucocytosis would indicate the presence of an ongoing infection and strengthen the probability of infectious GE (Hammer & McPhee, 2018; Huether & McCance, 2017). The other values in a CBC also provide baseline values that can later be used to compare with later tests and look for deviations.
2. CT scan or MRI: Computerized tomography scanning enables the visualization of the abdominal structures and organs in real time. Any pathophysiology would therefore be visible to the examining radiologist. For instance, if there will be visualization of outpouchings from the colon the obvious conclusion would be diverticulitis. In comparison, a magnetic resonance imaging (MRI) examination would be the most ideal since the resolution is superior and minute pathophysiologic details would be visible. Its use may however be limited by its cost.
3. Stool for microscopy: Having made a provisional diagnosis of GE, the most rational clinical decision would then be to order for a stool sample for microscopy (Hammer & McPhee, 2018; Huether & McCance, 2017). This would either confirm or disprove the diagnosis of infectious GE.
4. Metabolic panel: Since patient JR is both hypertensive and diabetic, it would make clinical sense to perform a metabolic panel as a baseline. This is because the current diagnosis is bound to affect the management and expression of these two comorbidities (Hammer & McPhee, 2018; Huether & McCance, 2017).
5. Urinalysis: Pain in the abdomen may be of genitourinary origin (Hammer & McPhee, 2018; Huether & McCance, 2017). This is the reason why it is important to investigate the GUT as well.
6. CRP: Lastly but not least, a C-reactive protein test would be clinically sound because it would give an indication of an ongoing infection process in the body (Hammer & McPhee, 2018; Huether & McCance, 2017).
   

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Diagnosis and Differential Diagnosis

I would accept the current diagnosis for the simple reason that the subjective and objective information available in this case seems to support it. The three possible conditions that qualify as differential diagnoses for patient JR are:

1. Infectious colitis

Infectious colitis is a very likely and possible diagnosis. This is because it is not uncommon for it to be comorbid with GE, as the primary diagnosis suggests and the ICD-10-CM code attests (Hammer & McPhee, 2018; Huether & McCance, 2017; Duncan, 2014).

2. Acute sigmoid diverticulitis

This is also a very likely differential diagnosis as it typically presents with LLQ abdominal pain (Hammer & McPhee, 2018; Huether & McCance, 2017).

3. Prostatitis

Prostatitis would be the last of the three. As stated above, the etiology of abdominal pain could also be the genitourinary system (Hammer & McPhee, 2018; Huether & McCance, 2017). Being a man in his late 40s, it is not unlikely that he may be suffering from prostatitis.

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Duncan, D. (2014). The pathophysiology of gastroenteritis. Independent Nurse, 2011(4). http://dx.doi.org/10.12968/indn.2011.4.4.83047

LeBlond, R.F., Brown, D.D., & DeGowin, R.L. (2014). DeGowin’s diagnostic examination, 10^th ed. McGraw Hill Medical.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6^th ed. Elsevier, Inc.  Assessing the Abdomen and Gastrointestinal System Essay Example