Lab Assignment: Assessing the Abdomen

Lab Assignment: Assessing the Abdomen

Introduction

Healthcare professionals provide high-quality care to a wide range of patients with varying health issues. They properly analyze the health conditions and diagnose and treat the patient. Abdominal conditions are common, particularly among the elderly, and nurses work to treat them. This essay will look at the case of a 47-year-old man who had experienced abdominal pain three days before. It will also examine the patient’s subjective and objective data, as well as what needs to be added and the differential diagnosis.

Subjective evaluation

Nurses collect this type of information about the patient’s experience with the condition. It primarily addresses the patient’s feelings and any concerns they may have. The nurse can gather a reasonable amount of subjective information from JR. The subjective information gathered will aid in the differential diagnosis. To begin, the nurse can use stomach pains as the patient’s primary complaint. The nurse can then learn about the patient’s history and current condition by asking several questions. The severity of the abdominal pain should be evaluated, as well as whether the pain is affecting other parts of the body (Dains et al., 2019). The nurse should also determine whether the pain is abrupt or gradual, as well as the location of the abdominal pain. A recent diet plan of the patient should also be obtained to determine if this is the source of the pain. More information about any changes in bowel movements should be gathered. Concerning the disease’s history, the nurse should emphasize when it began, the severity of the pain, and any other symptoms associated with the abdominal pain.

A three-generation family history will also be examined to determine if the disease is caused by genes (Dains et al., 2019). JR has a history of GI bleeding, so the nurse will need to see if there is any blood in his stool or if the color has changed. The patient’s diarrhea should be evaluated in terms of frequency and number of episodes per day. Finally, a thorough examination of the patient’s lifestyle should be performed to rule out hypertension and diabetes.

Data that is objective

The nurse obtains objective data from the patient’s physical examination via observation or palpation. The first objective data that the nurse will document will be JR’s general appearance. This includes his hygiene, mood, posture, how quickly he responds to questions, and how sick he appears to be (Ball et al., 2019). The majority of colon cancer patients appear pale or malnourished. Patients’ objective data must be in order, which is not the case here.

There is no overall evaluation of the patient. Nurses should document the body systems from HEENT to the neck or chest in the correct order. The nurse must use a stethoscope to determine whether the positive findings are definitive. Palpation and auscultation are also required for negative results. Palpation can help determine whether the abdomen is rigid or tender. Rigidity indicates that the patient has fluid accumulation obstructing the bowel. Because the patient has a history of GI bleeding, a CBC and cap refill are required. In addition, his blood glucose levels should be checked to determine the source of his diarrhea. X-rays, CBCs, and stool WBCs are also required. A colonoscopy should also be performed to assess his risk of developing colon cancer.

Whether or not the assessment is supported by subjective and objective evidence

JR’s evaluation is supported by both objective and subjective data. Subjective data, as previously stated, focus on the patient’s feelings about the disease. The patient mentions having diarrhea and vomiting. Objective data, on the other hand, focuses on the patient’s physical assessment. The documentation contains information on JR’s vital signs, including his intact skin with no lesions and no murmurs.

Diagnostic procedures

Diagnostic tests are performed to determine the patient’s correct diagnosis. The first diagnostic tests will be occult stool tests, which will look for signs of blood in the stool. If there is blood in the stool, it indicates that there is a problem in the upper digestive tract. The second diagnostic test will be a liver function test, which will help determine whether the liver is functioning normally and whether there are any abnormalities. A blood test to determine the blood count will be the third diagnostic test. An ultrasound of the abdomen is required to provide a better view of the organs and to detect any abnormalities. After the tests have yielded positive results, an X-ray will be performed.

Accepting or rejecting a diagnosis and an examination of potential conditions

In the case of JR, I would not accept the diagnosis because the evaluation was incomplete, and the patient suffers from lower quadrant pain. Due to symptoms such as fever, diarrhea, and vomiting, gastroenteritis is possible based on the subjective data provided above. The patient’s differential diagnoses include abdominal obstruction (Hussein et al., 2021).

When food does not reach the small or large intestines, this condition develops. Vomiting, cramps, constipation, and abdominal pain are among the symptoms (Horesh et al., 2016). Diverticulitis is the second possible diagnosis. This condition is characterized by pain in the lower left quadrant caused by diverticula swelling. As in the case of JR, symptoms include fever, vomiting, and abdominal pain. Because the patient has a history of GI bleeding, the final differential diagnosis is ulcerative colitis (Harbord et al., 2017). Diarrhea, fatigue, abdominal pain, and the need to empty the bowel are all symptoms of this condition.

References

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

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Harbord, M., Eliakim, R., Bettenworth, D., Karmiris, K., Katsanos, K., Kopylov, U., … & Carbonnel, F. (2017). Third European evidence-based consensus on diagnosis and management of ulcerative colitis. Part 2: Current management. Journal of Crohn’s and Colitis, 11(7), 769-784. doi:10.1093/ecco-jcc/jjx009

Horesh, N., Wasserberg, N., Zbar, A. P., Gravetz, A., Berger, Y., Gutman, M., Rosin, D., & Zmora, O. (2016). Changing paradigms in the management of diverticulitis. International Journal of Surgery, 33, 146–150. https://doi.org/10.1016/j.ijsu.2016.07.072

Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal Pain in the Elderly Patient: Point-of-care Ultrasound Diagnosis of Small Bowel Obstruction. Clinical Practice and Cases in Emergency Medicine, 5(1). https://doi.org/10.5811/cpcem.2020.11.50029

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Case Study

ABDOMINAL ASSESSMENT
Subjective:

CC: “My stomach has been hurting for the past two days.”

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led him to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd,  Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female

Objective:
VS: 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
Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
Diagnostics: US and CTA
Assessment:
Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis
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 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.