Lab Assignment: Assessing the Abdomen
Additional subjective data
It is essential to understand the associated symptoms of the pain, such as sweating, headache, or weakness. In addition, aggravating and alleviating factors for the pain should be included. The patient should also describe the pain characteristics as pressing, crushing, or pressing. The care provider should also assess for any weight changes, such as loss of weight and appetite.
Additional Objective data
Additional objective data include any visible skin color changes, visible masses or injury, and engorged veins (Ball et al., 2019). Palpating organs to determine guarding and organomegaly could also help accurately diagnose the patient. Another assessment includes any pain elicited during movement and urine and fecal clearance. The data will help develop a definitive diagnosis.
The objective and subjective data support the left lower quadrant pain assessment. The patient guards and groans when the left lower quadrant is touched. He complains that the pain is usually high at times (9/10). Pain location and characteristics are vital to diagnosing a patient.
Pain in the lower left quadrant could represent many illnesses, such as left glomerulonephritis and bowel inflammatory disease. Gastroenteritis entails inflammation of the stomach and intestine, leading to excruciating pain. According to Sattar and Singh (2021), nausea and vomiting are common in gastroenteritis, and they are accompanied by diarrhea, often due to indigestion due to the digestive system compromise.
The historical appearance of vomiting and diarrhea meets the diagnostic criteria for the condition. The pain can be located in the upper or lower quadrants, depending on whether the stomach or the intestines are inflamed. In addition, the patient has a history of GI bleeding, thus at high risk for developing gastroenteritis.
- The diagnostic tests appropriate for this case are a stool culture for microorganism identification
- WBCs to diagnose or rule out inflammation or internal bleeding.
- Electrolytes to determine imbalance and severity- the patient had diarrhea
- Serology for long-term infections
- Stool examination for cysts to rule out abdominal cysts or parasites
- Radio imaging through an x-ray or a CT would help determine structural anomalies such as a diverticulum of inflammation. These tests would be integral for the diagnosis and management of the patient.
Actual Diagnosis Analysis
I would not accept the current diagnosis of Abdominal aortic aneurysm. Golledge (2019) notes that AAA is asymptomatic in most patients, and only about ¼ of the patients show symptoms, including pulsating pain near the navel, deep constant abdominal pain, and back pain.
The pain in AAA is constant and does not change like the situation with our client. Escalation of the symptoms occurs when the aneurysm ruptures leading to disabling pain and internal hemorrhage, which can be potentially fatal.
Possible diagnoses or differentials include;
- Gastroenteritis. The patient characteristics match gastroenteritis presentation. The patient has generalized pain and reports pain and nausea after eating. The condition causes indigestion, which causes nausea and vomiting in the patient. Thus, gastroenteritis is the most appropriate diagnosis.
- Gastritis is another differential diagnosis of interest. The condition results from an inflation of the stomach lining. The pain is sharp in the left and right upper quadrants. Gastritis symptoms include nausea, abdominal pain, bloating, indigestion, and vomiting (Azer and Akhondi, 2021). The pain is explained as a burning sensation in the stomach. The patient presents with generalized pain, which is non-constant. Gastritis symptoms are sudden and disabling, unlike gastroenteritis, which presents with less severe symptoms that can resolve independently.
- The last differential diagnosis is GERD. According to Clarrett and Hachem (2018), gastroesophageal reflux disease is caused by the regurgitation of gastric contents into the throat. The contents are acidic and burn the throat hence a period of intense pain and, at times hoarse voice. Heard presents with excruciating intermittent pain, which often occurs after eating. The pain reports abdominal pain but denies hoarseness of regurgitating gastric contents. He also denies other symptoms such as dysphagia, odynophagia, cough, or sore throat. Healthcare providers must know about abdominal assessments and disease presentation for accurate diagnosis.
Azer, S. A., & Akhondi, H. (2021). Gastritis. In StatPearls [Internet]. StatPearls Publishing.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2021). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences.
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine, 115(3), 214. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/
Golledge, J. (2019). Abdominal aortic aneurysm: update on pathogenesis and medical treatments. Nature Reviews Cardiology, 16(4), 225-242. https://doi.org/10.1038/s41569-018-0114-9
Sattar, S. B. A., & Singh, S. (2021). Bacterial Gastroenteritis. In StatPearls [Internet]. StatPearls Publishing.
NURS 6512 LAB ASSIGNMENT: ASSESSING THE ABDOMEN SOAP NOTE
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-day history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPIs 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.
Medications: Metoprolol 50mg
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
- VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6â€™10â€; 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
- Abdominal Aortic Aneurysm (AAA)
- Perforated Ulcer
- Analyze the subjective portion of the (episodic) 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.
- Does subjective and objective information support the assessment? 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 conditions that may be considered a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.