A male went to the emergency room for severe mid-epigastric 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.
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Analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. Consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. Formulate a differential diagnosis with several possible conditions.
To Prepare
Review the Episodic note case study your instructor provided. 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.
THE QUESTION
· 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.
Assessment of the Abdomen and Gastrointestinal System
(The Episodic NOTE Case Study)
SUBJECTIVE DATA:
Chief Complain: “My stomach has been hurting for the past two days.”
History of Present Illness: 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.
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 DATA:
· 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
THE RUBRIC
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With regard to the SOAP note case study provided, address the following: Analyze the subjective portion of the note. List additional information that should be included in the documentation. |
10 (10%) – 12 (12%) The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation. |
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Analyze the objective portion of the note. List additional information that should be included in the documentation. |
10 (10%) – 12 (12%) The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation. |
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Is the assessment supported by the subjective and objective information? Why or why not? |
14 (14%) – 16 (16%) The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation. |
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What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? |
18 (18%) – 20 (20%) The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis. |
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· Would you reject or accept the current diagnosis? Why or why not? |
23 (23%) – 25 (25%) The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature. |
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Written Expression and Formatting – Paragraph Development and Organization: |
5 (5%) – 5 (5%) Paragraphs and sentences follow writing sta 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” Chapter 10, “Constipation” Chapter 12, “Diarrhea” Chapter 29, “Rectal Pain, Itching, and Bleeding” 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” (pp. 514–520)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., D WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2 WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2 Abdominal Assessment Case Study SOAP Note Subjective: •CC: “My stomach hurts, I have diarrhea, and nothing seems to help.” •HPI: JR, 47-year-old 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 PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Analyze the subjective portion of the note. List additional information that should be included in the documentation. Subjective Analysis According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates 
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