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The Case Study For Assessing The Abdomen Assignment Paper

The Case Study For Assessing The Abdomen Assignment Paper

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Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• 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. The Case Study For Assessing The Abdomen Assignment Paper

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NURS 6512N WEEK SIX ASSIGNMENT ONE INSTRUCTIONS

TOPIC: LAB ASSIGNMENT: ASSESSING THE ABDOMEN

 A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan. 

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 Lab 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 formulate a differential diagnosis with several possible The Case Study For Assessing The Abdomen Assignment Paper

 REQUIRED READING:

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach(10th ed.). St. Louis, MO: Elsevier Mosby.
    • 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 Download 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”Download 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”Download 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”Download 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.
    These sections below explain the procedural knowledge needed to perform gastrointestinal procedures.

    • Chapter 115, “X-Ray Interpretation of Abdomen” Download “X-Ray Interpretation of Abdomen”(pp. 514–520) The Case Study For Assessing The Abdomen Assignment Paper
      Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
  • Document: Midterm Exam Review Download Midterm Exam Review(Word document)

TO PREPARE:

Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

  • 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 five possible conditions that may be considered in a differential diagnosis for the patient.

Episodic note case study

Welcome to Week 6. This week, your students will complete an analysis of the SOAP note provided.  You can even  write this up as a narrative so that you  are able to correctly explain  your analysis. 

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.

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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. The Case Study For Assessing The Abdomen Assignment Paper

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

 

THE ASSIGNMENT

  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? The Case Study For Assessing The Abdomen Assignment Paper
  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.

Introduction- The Case Study

The patient is a 65-year-old African American male who presents to the ED with a history of abdominal pains for two days. The pain is in the mid-epigastric region, intermittent, and radiates to the back. He has used PPIs, which did not relieve the pain. The pain has been increasing in intensity over the past few hours and was associated with one episode of postprandial vomiting. There is no history of fever or diarrhea. He has a history of hypertension, GERD, and hyperlipidemia. He has been using metoprolol 50mg for the HTN. He has a history of alcohol use and cigarette smoking for 20 years but quit both drinking and smoking two years ago. On examination, his blood pressure is 91/60 mmHg and he is overweight with a BMI of 27.4. The abdominal exam revealed tenderness in the epigastric area with guarding. No masses or rebound tenderness.

Additional Subjective Information

From the patient’s presentation and the risk factors of cigarette smoking, hypertension, and hyperlipidemia, a diagnosis of abdominal aortic aneurysm is likely. Other information to ask on the history could include:

  1. Any history of connective tissue disorders like Marfan syndrome, which could predispose to AAA, or any history of peripheral arterial disease (Golledge et al., 2023)The Case Study For Assessing The Abdomen Assignment Paper.
  2. Any known family history of similar condition diagnosis or presentation
  3. I would also inquire more on the symptoms presentation to rule out other possible diagnoses for example whether the pain is worse or better with eating to rule out peptic ulcer disease.
  4. Are there any relieving or exacerbating factors such as eating or posture
  5. I would also ask whether the patient has noticed any blood in stools or dark stools to rule out the possibility of gastrointestinal bleeding.

Additional Objective Information

From the examination, the patient is hypotensive, which could indicate internal bleeding from the rupture of the aneurysm. I would also check the SPO2 to rule out hypoxia and ABGs to assess for tissue hypoxia. On examination of the abdomen, I would check for any distension or pulsations in the epigastric area. I would also check for the large pulses in the arms and legs to assess whether they are reduced.

The Assessment

The assessment made included the differential diagnoses of AAA, pancreatitis, and perforated ulcer. These are supported by the patient’s history and examination results. In the subjective data, the patient’s abdominal pains are epigastric radiate to the back, and were associated with an episode of vomiting. He also has a long history of cigarette smoking and alcohol use, hypertension, and hyperlipidemia. These are the greatest risk factors for AAA and thus support the diagnosis (Ayraler, 2023). The risk factors could also predispose to pancreatitis, which also presents with epigastric pain (Gapp et al., 2023)The Case Study For Assessing The Abdomen Assignment Paper. It can however be ruled out because of the absence of fever, nausea, and pain that worsens with eating.

Diagnostic Tests

  1. Abdominal ultrasound- This will evaluate the abdomen for any abnormalities like bleeding or an AAA that can cause abdominal pains (Shaw et al., 2023).
  2. CT angiogram and MRI abdomen to evaluate the AAA

The Diagnosis

I agree with the diagnosis of an abdominal aortic aneurysm based on the patient’s history and presentation as explained above. The longstanding history of cigarette smoking and hyperlipidemia, and the presentation of intermittent abdominal pain not relieved by PPIs or worsened by meals support the diagnosis (Golledge et al., 2023)The Case Study For Assessing The Abdomen Assignment Paper. The other possible differential diagnosis apart from pancreatitis and PUD would be intestinal obstruction, intestinal ischemia, and ruptured abdominal aortic aneurysm because of the hypotension.

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 References

Ayraler, A. (2023). Abdominal aortic aneurysm: A case report. Medicine International3(5). https://doi.org/10.3892/mi.2023.103

Gapp, J., Tariq, A., & Chandra, S. (2023, February 9). Acute pancreatitis – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK482468/

Golledge, J., Thanigaimani, S., Powell, J. T., & Tsao, P. S. (2023). Pathogenesis and management of abdominal aortic aneurysm. European Heart Journal44(29), 2682-2697. https://doi.org/10.1093/eurheartj/ehad386

Shaw, P. M., Loree, J., & Gibbons, R. C. (2023, March 21). Abdominal aortic aneurysm – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK470237/ The Case Study For Assessing The Abdomen Assignment Paper

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