Abdominal Assessment

In this Assessment 1 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 identify three possible conditions that may be considered as a differential diagnosis for this patient.(Abdominal Assessment Essay Example)

1.      Analyze the subjective portion of the note. List additional information that should be included in the documentation.

2.      Analyze the objective portion of the note. List additional information that should be included in the documentation.

3.      Is the assessment supported by the subjective and objective information? Why or why not?

4.      What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

5.      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.

This week, you will complete an analysis of the SOAP note provided. I advise you to write this up as a narrative so that they are able to correctly explain the analysis.  I would suggest having your grading rubric out for this assignment so you clearly address  each section that needs to be covered to receive all points for this assignment.(Abdominal Assessment Essay Example)

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’s 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 his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.(Abdominal Assessment Essay Example)

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:

1.      Abdominal Aortic Aneurysm (AAA)

2.      Perforated Ulcer

3.      Pancreatitis

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

·         With regard to the Episodic note case study provided:

o    Review this week’s Learning Resources, and consider the insights they provide about the case study.

o    Consider what history would be necessary to collect from the patient in the case study.

o    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?

o    Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

-I have attached an example

Abdominal Assessment Essay Example-Solution

Soap Note Analysis

The soap note framework enables practitioners to assess and treat patients in a holistic manner. The soap note includes all the subjective and objective information, which facilitates accurate assessments and the creation of patient-centered plans. SOAP notes facilitate clinical reasoning by providing patient-specific information that can be used to assess, diagnose, and treat a patient. This analysis examines the abdominal soap note sections to determine any missing information and ensure accurate and patient-specific diagnosis.(Abdominal Assessment Essay Example)

Subjective

Documentation under the subjective portion focuses on the patient’s personal views, experiences, or feelings or someone close to them. The section provides context and guides the assessment and plan for the patient. Subjective data includes the chief complaint, history of present illness (HPI), current medications and allergies, history, and systems review. The history part in subjective data covers past medical history, past surgical history, reproductive history, social history, family history, and immunization history. The review of systems documentation covers general, gastrointestinal, and musculoskeletal assessments and guides the discovery of symptoms.(Abdominal Assessment Essay Example)

The soap note captures key HPI information but fails to include the alleviating and aggravating factors that make the CC better or worse. HPI information should also include temporal factors that highlight whether the CC gets worse or better at specific times of the day, in addition to the type of foods that upset the patient’s stomach, the patient’s appetite, food intolerance, dysphagia, bowel habits, and include a nutritional assessment. This information would provide much need context on the patient’s complain(Abdominal Assessment Essay Example). The notes could also include any past abdominal history, immunization history, reproductive history, and the patient’s lifestyle. The subjective part also misses ROS, which is essential in holistically assessing the patient. Hence it is imperative to conduct a ROS that assesses the general information, HEENT, respiratory, cardiovascular, GI, gastrourinary, MS, and additions such as psychological, neurological, integument, endocrine, and allergic information. A comprehensive subjective section ensures the practitioner documents all the symptoms of the patient.(Abdominal Assessment Essay Example)

Objective

The objective section includes documentation on the physical exam and vitals of the patient. The note includes the patient’s vitals, heart, lungs, skin, abdominal, and diagnostics data. Besides, the objective portion should include the patient’s dehydration status, any skin conditions or signs, palpations, auscultation, and perfusion. Besides the vital signs and physical exam findings documented, the section should include laboratory data on the patient. The inclusion of lab results on diagnostic tests is essential in guiding accurate diagnosis and developing a patient-specific plan.

(Abdominal Assessment Essay Example)

Assessment

The assessment narrows down to left lower quadrant pain and gastroenteritis. This assessment is supported by subjective and objective information, which indicates the findings that lead to the primary assessment. The objective information guides the diagnosis by highlighting l, while HPI provides the context of the severity, duration, and character of the pain and complaint.(Abdominal Assessment Essay Example)

Diagnostic tests

In this case, stool tests would be appropriate if the patient reports fever or blood in the stool. The stool test would help accurately diagnose the patient, especially in determining an infection, poor nutrient absorption, or cancer. Moreover, an ultrasound or CT scan may also be beneficial. An MRI scan can also be conducted to assess the lower quadrant pain. The MRI would offer a better resolution of the soft tissues without exposing the patient to radiation.(Abdominal Assessment Essay Example)

Current Diagnosis and Differential Diagnoses

As shown by the symptoms from subjective data and signs from objective information, the current diagnosis is accurate. Gastroenteritis is characterized by diarrhea, abdominal pain, nausea or vomiting, and low-grade fever, exhibited by the patient. The differential diagnosis for the patient would include:(Abdominal Assessment Essay Example)

1. Irritable bowel syndrome (IBS): It is a chronic condition characterized by abdominal pain and bowel habits alterations. IBS is diagnosed by symptom onset greater than six months and recurrence at least three days per month during the last three months (Weaver, Melkus, & Henderson, 2017). This is not the case for the patient, which rules out an IBS diagnosis.(Abdominal Assessment Essay Example)
2. Inflammatory bowel disease is associated with repetitive inflammation episodes of the gastrointestinal tract caused by an abnormal immune response to gut microflora. Despite abdominal pain and nausea, the patient has no inflammation indicators, thus refuting an IBD diagnosis (McDowell, Farooq, & Haseeb, 2020).(Abdominal Assessment Essay Example)
3. Food Poisoning (FP):- Is characterized as illnesses caused by bacteria or other toxins in food, typically with associated vomiting and diarrhea. Other symptoms include fever, abdominal cramping, headache, dehydration, myalgia, and arthralgias (Switaj, Winter, & Christensen, 2015). This diagnosis was refuted based on findings of the physical exam.(Abdominal Assessment Essay Example)

Conclusion

In conclusion, the soap notes partially assess the patient’s subjective and objective information. In the subjective section, more information should be documented on food intolerance, nutritional assessment, alleviating or aggravating factors, and appetite. More data should be added on the dehydration status, inspection, and auscultation in the objective section. Based on the subjective and objection information, a patient-specific treatment plan can be created for the patient.(Abdominal Assessment Essay Example)

References

McDowell C, Farooq U, Haseeb M. Inflammatory Bowel Disease (IBD) [Updated 2020 Jun 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470312/

Nemati, S., & Teimourian, S. (2017). An Overview of Inflammatory Bowel Disease: General Consideration and Genetic Screening Approach in Diagnosis of Early Onset Subsets. Middle East journal of digestive diseases, 9(2), 69–80. https://doi.org/10.15171/mejdd.2017.54

Switaj, T. L., Winter, K. J., & Christensen, S. (2015). Diagnosis and management of foodborne illness. American family physician, 92(5), 358-365.(Abdominal Assessment Essay Example)

Weaver, K. R., Melkus, G. D., & Henderson, W. A. (2017). Irritable Bowel Syndrome. The American journal of nursing, 117(6), 48–55. https://doi.org/10.1097/01.NAJ.0000520253.57459.01