Assignment 1: Lab Assignment: Assessing the Abdomen 

To Prepare

Review the Episodic note case study below for this week’s Assignment. 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 three to five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

  1.  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.

Week 6: Assessment of the Abdomen and Gastrointestinal System 

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, hyperactive bowel sounds, pos pain in the LLQ 

• Diagnostics: None 

Assessment: 

• Left lower quadrant pain 

• Gastroenteritis 

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.

  • Chapter 6, “Vital Signs and Pain Assessment”

    This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
  • Chapter 18, “Abdomen”

    In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.

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.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 3, “Abdominal Pain”
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”
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”
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”
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.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

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Subjective Portion

The patient presents to the hospital with complaints of stomach pain and diarrhea. Therefore in the subjective portion of the note, there should be more investigation of history of present illness (HPI). A focused gastrointestinal assessment should comprise of a thorough history of abdominal or gastrointestinal complaints of the patient (“Focused Gastrointestinal Assessment”, 2019). The clinician should strive to understand any changes in appetite, weight gain or loss, nausea or vomiting, intolerance to certain foods, and dysphagia. The clinician should ask the patient if they have had any changes in food intake or appetite. If the patient responds in the affirmative, then the clinician should ask for more information about the changes. According to “Focused Gastrointestinal Assessment” (2019), the patient’s appetite and eating behaviors can become influenced by many factors that can indicate gastrointestinal disease. The clinician should also document any changes in weight, either gain or loss. In the case of weight loss, this can be associated with illness, and weight gain can be associated with fluid retention or a mass (Jarvis, 2020). The clinician should also ask the patient if they have an intolerance to a certain food, and if so, the physician should seek to understand the type of reaction to the food. Lastly, the clinician should ask the patient if they are experiencing dysphagia, which is difficulty swallowing, and they can experience pain while swallowing.

Objective Portion

In the objective portion of the soap note, more details are required in the physical exam of the patient’s gastrointestinal system. The clinician should conduct some tests that include an upper GI test that is a test that seeks to look at the patients’ GI tract that includes the esophagus, the stomach, and the duodenum (Ball, Dains, Flynn, Solomon & Stewart, 2019). The physician should also conduct a thorough physical examination while following the various methods of physical examination and health assessment such as inspection, palpation, percussion, and auscultation (Dains, Baumann & Scheibel, 2019). All these examinations can help in revealing the illness affecting the patient. Since the patient has diarrhea, the physician should consider conducting an endoscopy, which is a procedure where the physician uses an endoscope to examine the interior of the patient’s body. Some of the most adopted strategies is the use of a flexible sigmoidoscopy that evaluates the lower part of the large intestine and can help in understanding the cause of diarrhea (Dains, Baumann & Scheibel, 2019).

Is Assessment Supported by Subjective and Objective Information

The assessment is not fully supported by subjective and objective information. Therefore, more tests should have assisted in narrowing down to the differential diagnosis. Based on the subjective and objective information, the assessment indicated that the patient had left lower quadrant pain and gastroenteritis. Conducting more tests while collecting the objective data could have facilitated understanding the primary cause of the abdominal pain.

Diagnostic Tests Appropriate

Conducting more diagnostic tests could assist the physician to narrow down on a possible illness affecting the patient. In addition to the various tests conducted on the patients, the physician should have conducted a rapid stool test that can help diagnose and follow up of gastrointestinal disorders (Kasırga, 2019). Pertinent information about the disease affecting the gastrointestinal system of the individual can be obtained with stool examination. The physician can examine stool chemically, microscopically, and macroscopically (Kasırga, 2019). The physician should examine the stool in terms of color, consistency, form, odor, quantity, and presence of mucus.

View on Current Diagnostic Diagnosis

I would agree with the current diagnosis of left lower quadrant pain and gastroenteritis since the symptoms of gastroenteritis, which is also known as infectious diarrhea, cause diarrhea, vomiting, and abdominal pain. In addition to gastroenteritis and left lower quadrant pain, the differential diagnosis includes; diverticulitis, viral meningitis, and colitis.

Diverticulitis is an infection or inflammation of pouches that can form in the intestines. Some of the symptoms of diverticulitis include cramping in the left side of the abdomen, and there might be an increase in diarrhea and bowel irritability (Jung et al., 2010).

Viral meningitis is also known as aseptic meningitis, which is caused by a viral infection. It results from the inflammation of the meninges. Some of the symptoms of the illness include headache, vomiting, and stomach cramps.

Colitis is a chronic digestive disease that is characterized by inflammation of the inner lining of the colon. Inflammation of the colon causes colitis. Some of the colitis symptoms include diarrhea, which in most cases, is with blood or pus, rectal pain, abdominal pain, and weight loss (Park et al., 2014). For the physician to understand the illness that is affecting the patient, this necessitates the need for various tests that can ascertain whether the patient has diverticulitis, viral meningitis, and colitis. In most cases, the stool test can narrow down the illness since the physician can understand the color of the stool and whether the stool has blood and mucus. Having a thorough understanding of the characteristics of the stool can enable the physician to give the correct medication.

References

Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2019). Seidel’s guide to physical examination (9th ed.). St. Louis: Elsevier Mosby.

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

Focused Gastrointestinal Assessment. (2019). Retrieved 10 January 2021, from https://lms.rn.com/getpdf.php/2054.pdf

Jarvis, C. (2020). Physical Examination and Health Assessment E-Book (8th ed.). London: Elsevier Health Sciences.

Jung, H., Choung, R., Locke, R., Schleck, C., Zinsmeister, A., & Talley, N. (2010). Diarrhea-Predominant Irritable Bowel Syndrome Is Associated With Diverticular Disease: A Population-Based Study. American Journal Of Gastroenterology105(3), 652-661. doi: 10.1038/ajg.2009.621

Kasırga, R. (2019). The importance of stool tests in diagnosis and follow-up of gastrointestinal disorders in children. Turk Pediatri Ars54(3), 141–148. doi: 10.14744/turkpediatriars.2018.00483

Park, S., Ye, B., Yang, S., Kim, S., Kim, J., & Kim, J. et al. (2014). Clinical features and course of ulcerative colitis diagnosed in asymptomatic subjects. Journal Of Crohn’s And Colitis8(10), 1254-1260. doi: 10.1016/j.crohns.2014.03.002