NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay

Walden University NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

 

How to Research and Prepare for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay                     

 

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

 

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

 

How to Write the Introduction for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay                     

The introduction for the Walden University NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

 

How to Write the Body for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay                     

 

After the introduction, move into the main part of the NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

 

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

 

How to Write the Conclusion for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay                     

 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

 

How to Format the References List for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay                     

 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Assessing the Abdomen

Gastrointestinal disorders are common encounters in nursing practice with considerable public health impacts. Nurses and other healthcare providers should perform comprehensive history taking and physical examinations to develop accurate diagnoses and care plans. Therefore, this essay examines J.R.’s case study. J.R. presented to the hospital with complaints of having generalized abdominal pain that began three days ago. He has been experiencing diarrhea that has been unresponsive to any treatments adopted by the patient.  The essay analyzes additional subjective and objective information that should be obtained from the client if subjective and objective data supports the assessment, diagnostic tests, and possible differential diagnoses.

Additional Subjective Information

            Additional subjective information should be obtained to guide the development of an accurate diagnosis. First, information about the things that might have led to the abdominal pain should be obtained. This includes data such as diet, alcohol consumption, or possible trauma that could have led to the symptoms. Information about previous experiences of stomach pain should also be obtained. A previous history of stomach pain will help the nurse determine if the condition is acute or chronic. In addition, the nurse should determine if JR experienced a similar pain when he experienced gastrointestinal bleeding four years ago. Information on previous treatments for the GI bleed should be obtained to guide the current management. The nurse should also seek information about the characteristics of stomach pain (Maret-Ouda et al., 2020). For example, information on whether the pain radiates elsewhere should have been obtained to rule out causes such as pancreatitis.

            Information about the character of the diarrhea should also be obtained. Information such as blood-stained diarrhea would help the nurse to develop a potential diagnosis of gastrointestinal tract bleeding. Associated symptoms such as vomiting should also be obtained. This is important because symptoms such as projectile vomiting will indicate potential problems such as pyloric stenosis. Information about changes in the client’s weight over the past few months should also be obtained. Unintentional weight loss could indicate other health problems such as cancer of the gastrointestinal system. Information on changes in appetite should also be sought. Early satiety could indicate problems such as hypertrophic pyloric stenosis. The nurse should also obtain information about the factors that relieve, precipitate, or worsen the stomach pain. For example, a diagnosis of peptic ulcer disease will be made if the symptoms worsen 15-30 minutes after eating (Sverdén et al., 2019). A diagnosis of gastroesophageal reflux disease will be made if the symptoms worsen when JR lies down and improves with sitting upright.

NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen Sample Essay

NURS 6512 Week 6 Assignment 1 Lab Assignment Assessing the Abdomen Sample Essay

The SOAP note’s 65-year-old Black American male patient arrives at the emergency room complaining of sporadic epigastric stomach ache that radiates to his back. When he went to the neighboring urgent care facility, PPIs were provided to him without providing any relief. The patient reported that the pain had been worse over the preceding few hours and he had vomited the afternoon when he finally went to the emergency department. He hasn’t had a fever, diarrhea, or any other signs often associated with stomach discomfort. The purpose of this paper is to demonstrate how to evaluate the offered subjective and objective data to determine the patient’s primary and differential diagnoses.

Subjective Portion

According to the OLDCARTS technique, the HPI lacks information on the kind, intensity, and aggravating and alleviating elements of the pain. In addition, there is no information on the color or consistency of vomit (Ball et al., 2019).The date of the HTN diagnosis and if the illness has been treated are missing from the PMH. This section ID also lacks information on previous hospitalizations and surgical histories. The dosage and frequency of metoprolol are not listed in the medication section. The allergy section does not address allergies to food, the environment, or latex. A family history should include information on all first-degree relatives, including parents, grandparents, siblings, and their children. Add details on the person’s age, whether they’re living or deceased, and how they’re feeling. Any dead relatives’ age and method of death should also be mentioned. Age and any ailments should be mentioned if the person is still alive. It should also include a list of mental health issues including depression, addiction, and substance misuse.

Owing to the patient’s digestive issues, a comprehensive series of subjective GI system questions should be made, including Has the digestive illness continued for a considerable amount of time? Burning in the substernal area or the chest? Does your tummy hurt? struggling to swallow? Does swallowing hurt? Is it vomiting or nausea? abdominal bloating or distention? Have yellow skin (jaundice)? vomiting that is hemorrhagic (hematemesis)? stool that is dark or tarry? Scratched stools? Constipation? diarrhea or other alterations to bowel habits (Weledji, 2020). Patients do not receive Hepatitis A or B vaccines.

Objective Portion

The general assessment of the patient is not standardized. The vital signs section does not include the patient’s oxygen saturation or BMI. Every recent journey should be taken into account to assess GI problems related to travel. The physical exam of the skin should cover any skin changes, notably any yellowing that would suggest jaundice from cholestasis (Ball et al., 2019). Since changes in urine color can be an indication of cholestasis, a disorder in which the kidneys eliminate direct bilirubin from the serum, this topic belongs under the genitourinary area.

When a patient complains of stomach pain, nausea, and/or vomiting, the Gastrointestinal system should be thoroughly evaluated. The four quadrants of the abdomen should be evaluated using sonography, percussion, and palpation, as well as objective data from examining and assessing the abdomen for shape, scars, pigmentation, symmetry, and abnormal protrusions. Because cholestasis may be associated with pale-colored feces, stools should be inspected for color. Blood in the stool is investigated to rule out GI hemorrhage (Gallaher & Charles, 2022). Variations in appetite, nutrition, or food consumption must be taken into consideration in this assessment. For evaluating organ performance, it is essential to get the missing laboratory results.

Assessment Supported

A history of alcohol consumption supports the diagnosis of pancreatitis in the context of symptoms such as nausea, vomiting, and epigastric pain that radiates to the back (Hamm, 2021). Other tests to support pancreatitis diagnosis include elevated amylase and/or lipase levels that are 3 times higher than the upper limit of normal. Moreover, the CT ought to back up this diagnosis.

This diagnosis of AAA is unsupported because the patient in this case seems stable and lacks several of the crucial presenting symptoms. This diagnosis necessitates figuring out whether or not the AAA is raptured based on the symptoms that are now present. The majority of cases with AAA are undiagnosed and asymptomatic (Weledji, 2020). The initial imaging procedure necessary for this diagnosis, if the patient is not allergic to contrast or pregnant, is a CT scan with contrast.

A perforated ulcer is not supported by either subjective or objective facts. A burst peptic ulcer is identified by the classic trifecta of sudden onset of abdominal rigidity, tachycardia, and stomach distress. Both the patient’s heart rate and the abdomen are not tachycardic (Ball et al., 2019). A history of smoking is the only risk factor for PUD; the patient does not use any NSAIDS or steroids.

Diagnostic Tests

Many medical conditions can cause abdominal discomfort, and numerous tests may be necessary to identify the reason. In addition to a health history and physical exam, laboratory tests for blood, urine, stool, and enzymes may be utilized to aid in diagnosis. Abdominal abnormalities can also be found with imaging tests (Ball et al., 2019). Diagnostic tests will include an Electrocardiogram, which would disclose any aberrant cardiac findings and exclude ischemia due to the patient’s specific presentation of stomach discomfort.

Blood tests including the Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), and stool samples for magnesium and phosphorus are examples. To completely rule out an infection, they are crucial (Weledji, 2020). As the patient complains of frequently having diarrhea, the CMP would provide a current health status of the kidneys, liver, and electrolytes. Test for Liver Enzymes and Hepatic Function These examinations reveal how well the liver is working. This examination will demonstrate if the liver is successfully removing the body’s toxins, which may result in severe stomach discomfort. This is crucial because a portion of the liver can be found in the epigastric region 4.

Rejection or Acceptance

Unless more testing is done, I would not accept the diagnosis of AAA. While this patient complains of sporadic discomfort, his vital signs are stable, and even though individuals with AAA frequently arrive with tearing or ripping chest pain, this patient does not characterize his pain in such terms(Hafeez et al., 2018).

The major diagnosis is acute pancreatitis, which I accept. Hafeez et al. (2018) claim that acute pancreatitis may be diagnosed initially without the use of imaging and that the presence of stomach discomfort together with high lipase or amylase levels can help to confirm this diagnosis. Also, the patient has a known etiology such as alcoholism and hyperlipidemia (Grigorian et al., 2019).

Possible Conditions

Gastritis may be the cause of the abrupt onset of epigastric discomfort, nausea, and vomiting (Weledji, 2020). It could be brought on by elements like smoking and drinking, which LZ’s past demonstrates. The patient might additionally have gastritis as a result of stress, such as losing his job.

Ulcer perforation: For two days, the patient’s condition, such as stomach pain, grew worse. This is how ulcer perforation presents. From modest stomach aches to severe agony and tachycardia, it goes through many stages (Yamamoto et al., 2018). H. pylori infection or regular use of NSAIDs, which can damage the stomach lining, maybe the cause of this.

Cholecystitis causes the gallbladder to swell up. With nausea, purging, and fever as their accompanying symptoms, biliary colic is an increasing pain in the right upper quadrant that may progress to the back (Gallaher & Charles, 2022). Jaundice is evident depending on the degree of gallbladder neck obstruction. The attack typically happens after a large, fatty meal. The pain eventually develops into a little upper-right stomach discomfort or a nagging ache. Abdominal ultrasound can identify calcified gallstones, and elevated white blood cell counts in the test findings can help to make the diagnosis.

Conclusion

The 65-year-old Black American male patient is likely suffering from gastritis. This may be the cause of the abrupt onset of epigastric discomfort, nausea, and vomiting.In addition to the pertinent lab testing to rule out the differential diagnosis, additional findings that might assist corroborate this diagnosis have been noted above. Correct diagnosis is essential for fostering the creation of the most efficient care strategy.

References

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.ISBN: 9780323545389

Gallaher, J. R., & Charles, A. (2022). Acute Cholecystitis: A Review. JAMA, 327(10), 965–975. https://doi.org/10.1001/jama.2022.2350

Grigorian, A., Lin, M. Y., & de Virgilio, C. (2019). Severe epigastric pain with nausea and vomiting. Surgery, 227–237. https://doi.org/10.1007/978-3-030-05387-1_20

Hafeez, A., Karmo, D., Mercado-Alamo, A., & Halalau, A. (2018). Aortic dissection presenting as acute pancreatitis: Suspecting the unexpected. Case Reports in Cardiology, 2018, 1–4. https://doi.org/10.1155/2018/4791610

Hamm, R. G. (2021). Acute Pancreatitis: Causation, Diagnosis, and Classification Using Computed Tomography. Radiologic Technology, 93(2), 197CT219CT. https://pubmed.ncbi.nlm.nih.gov/34728586/

Weledji, E. P. (2020). An Overview of Gastroduodenal Perforation. Frontiers in Surgery, 7. https://doi.org/10.3389/fsurg.2020.573901

Yamamoto, K., Takahashi, O., Arioka, H., & Kobayashi, D. (2018). Evaluation of risk factors for perforated peptic ulcer. BMC Gastroenterology, 18(1). https://doi.org/10.1186/s12876-018-0756-4

Abdominal Assessment

Nurses and other healthcare providers play an important role in the promotion of health of diverse patient populations. They utilize their knowledge and skills in patient assessment to determine the actual and potential health needs of their patients. Abdominal health problems are part of the conditions that nurses address in their daily practice. Therefore, this essay examines a case study of a patient that came with abdominal health problem. The patient is a 47-year-old male that complained of generalized abdominal pain, which started 3 days ago. The essay examines the additional subjective and objective data that should be obtained from the patient, diagnostic investigations, and differential diagnoses that should be considered.

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Subjective Analysis

Subjective information refers mainly to the data that healthcare providers obtain concerning the experiences of the patients with a health problem. Subjective data explores a wide range of aspects of a disease such as the concerns and feelings of the patient. A number of subjective information should be obtained from JR. One of them is the character of the abdominal pain. Besides the rating and intensity of the abdominal pain, questions related to aggravating, precipitating and relieving factors should be obtained. There is also a need to obtain information on whether the pain radiates to other parts of the body, generalized, increasing or decreasing in severity or not.

Information about the pain such as its character such as being gradual or of sudden onset should also be obtained. Additional information about the diarrhea should also be obtained. For example, the frequency and number of diarrhea experienced in a day should be obtained. This is important as it provides clues into the hydration status of the patient. Information about the aggravating, precipitating, and relieving factors for diarrhea should also be obtained (Perry et al., 2021). Recent dietary history and habits should also be explored to determine the potential cause of the health problem. The history obtained from the JR indicates that he has a history of GI bleeding. It is therefore important to ask information related to whether there is blood stained stool, smell and color to determine the exact cause of the problem. Comprehensive acquisition of subjective information is therefore crucial to guide the development of the most accurate diagnosis for JR.

Objective Analysis for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen

Objective data refers to the information that the healthcare provider obtains through physical

examination. It entails the use of techniques such as observation, auscultation, percussion, and palpation. Objective data is mainly used to validate subjective data and develop accurate diagnosis of a problem affecting a client. A number of objective data needs to be obtained from the client in the case study. The first aspect of objective data is documenting the general appearance of JR. Information about the general appearance of the patient such as if well dressed and sick looking should have been obtained. Patients with chronic illnesses such as colon cancer may appear lethargic and malnourished.

JR should have also been examined for jaundice and hydration status. Inspection of the abdomen should also be done to determine whether there is abdominal distention. Abdominal distention may lead to the development of diagnoses such as organomegally or pancreatic cancer. Observation should also aim at determining if there are any scars and distended veins. Palpation should also be done to determine if there is abdominal rigidity, tenderness, or rebound tenderness. Rigidity could indicate accumulation of fluid or abdominal matter in the peritoneal cavity, hence bowel obstruction (Cox, 2019). Therefore, the above objective data would guide the development of accurate diagnosis for the client.

If the Assessment is supported by Subjective and Objective Information

The assessment in the case study is supported by objective and subjective information. As noted initially, subjective data focuses on the perceptions and feelings of the patient with a disease. JR reported subjective data such as diarrhea and vomiting. He also reported pain and history of GI bleeding. Objective data focuses on the information that the healthcare provider obtains through physical assessment (Estes et al., 2019). The data such as vital signs, absence of murmurs, and intact skin without lesions are some of the objective information in the case study.

Diagnostic Tests for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen

Additional diagnostic tests should be performed to come up with an accurate diagnosis of the health problem that the client in the case study is experiencing. One of the tests would be stool occult test to determine if there is blood in the stool or not. The other test is complete blood count to determine if the client has infection. Liver function tests may also be performed to determine whether there is an abnormality with liver enzymes, which indicate liver disease. Ultrasound of the abdomen may also be needed to view the abdominal organs for any abnormality (Williams, 2021).

Accepting or Rejecting Diagnosis and Possible Conditions

I would reject the diagnosis for NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen. The assessment was not comprehensive. For example, it did not examine the lower quadrant pain to determine its character. The subjective data points towards a possible diagnosis of gastroenteritis. The presence of abdominal pain, low-grade fever, vomiting and nausea are often associated with gastroenteritis. One of the differential diagnoses for JR in this case study is abdominal obstruction. Patients with abdominal obstruction often experience symptoms such as abdominal pains, vomiting, nausea, and vomiting.

However, this condition is least likely due to the presence of diarrhea (Perry et al., 2021). The other possible differential diagnosis is pancreatic cancer. Patients with pancreatic cancer may experience symptoms such as abdominal pains, nausea, and vomiting. However, this should be ruled out by performing comprehensive history taking and physical examination. Diagnostic investigations such as abdominal ultrasound will help determine if JR is suffering from pancreatic cancer. The last differential diagnosis is diverticulitis. Diverticulitis is also associated with left lower quadrant pain, nausea, fever, and vomiting (Williams, 2021). The condition should be ruled out through a CT scan of the abdomen.

Conclusion

In conclusion of NURS 6512 Week 6 Assignment 1 Lab Assignment: Assessing the Abdomen, comprehensive assessment and physical examination is important in patient care. Additional subjective and objective data should be obtained from the patient in the case study to develop an accurate diagnosis. In addition, diagnostic investigations should be done to determine the actual cause of the abdominal problem. Differential diagnoses should be considered to guide the development of the treatment plan.

References

Cox, C. L. (2019). Physical Assessment for Nurses and Healthcare Professionals. John Wiley & Sons.

Estes, M. E. Z., Calleja, P., Theobald, K., & Harvey, T. (2019). Health Assessment and Physical Examination. Cengage AU.

Perry, A. G., Potter, P. A., Ostendorf, W., & Laplante, N. (2021). Clinical Nursing Skills and Techniques—E-Book. Elsevier Health Sciences.

Williams, P. A. (2021). Fundamental Concepts and Skills for Nursing—E-Book. Elsevier Health Sciences.

The SOAP note concerns a 47-year-old white man with chief complaints of abdominal pain and diarrhea. He has had generalized abdominal pain for three days but has not taken any meds to relieve the pain. He reports that the pain was initially at 9/10 but has reduced to 5/10, and he cannot eat due to ensuing nausea. His medical history is positive for

hypertension, DM, and GI bleeding. GI exam findings include a soft abdomen, hyperactive bowel sounds, and LLQ pain. The purpose of this paper is to analyze the SOAP note, identify appropriate diagnostic tests, and discuss likely diagnoses.

Subjective Portion

The SOAP note’s HPI describes the abdominal pain, including the onset, location, associated symptoms, and severity of pain. Nevertheless, the HPI should have given an additional description of the abdominal pain, particularly the duration of the abdominal pain, timing (before, during, or after meals), and frequency. In addition, the characteristics of the abdominal pain should be included describing if the pain is sharp, crampy, dull, colicky, diffuses, constant, or radiating (Sokic-Milutinovic et al., 2022).

In addition, the HPI should have included the exacerbating and alleviating factors for the abdominal pain and to what level the alleviating factors relieve the pain. Furthermore, the HPI has described only the abdominal pain leaving out diarrhea. It should describe diarrhea, including the onset, timing, frequency, characteristics of the stools (watery, mucoid, bloody, greasy, or malodorous), and relieving and aggravating factors.

The subjective part should have included the patient’s immunization status with a focus on the last Tdap, Influenza, and COVID shots and surgical history. The social history has scanty information and should have included the patient’s education level, occupation, current living status, hobbies, exercise and sleep patterns, dietary habits, and health promotion interventions (Gossman et al., 2020). Lastly, a review of systems (ROS) is mandatory for a SOAP note. Thus, the SOAP note should have a ROS that indicates the pertinent positive and negative symptoms in each body system, which helps identify other symptoms the patient has not reported in the HPI.

Objective Portion

The objective part misses critical information like the findings from the general assessment of the patient, which should include the client’s general appearance, personal hygiene, grooming, dressing, speech, body language, and attitude towards the clinician. In addition, findings from a detailed abdominal exam should have been provided. For instance, it should have inspection findings, including the abdomen’s pigmentation, respiratory movements, symmetry, contour, and presence of scars.

Additional auscultation findings that should be indicated include the presence of friction ribs, vascular sounds, and venous hum. It should also have exam findings from palpation and percussion, including abdominal tenderness, masses, organomegaly, guarding, or rebound tenderness (Sokic-Milutinovic et al., 2022). Besides, the liver span and spleen position should be indicated.

Assessment

The assessment findings identified in the SOAP note are Left lower quadrant (LLQ) pain and gastroenteritis (GE). LLQ pain is supported by subjective findings of abdominal pain and LLQ tenderness on exam. GE is consistent with subjective data of diarrhea, abdominal pain, and nausea and objective data of low-grade fever of 99.8 and hyperactive bowel sounds, which are classic symptoms.

Diagnostic Tests

The appropriate diagnostic tests for this patient are stool culture, complete blood count (CBC), and abdominal ultrasound. A stool culture is crucial to look for ova and cyst, which will help establish the causative agent for diarrhea and guide the treatment plan. Based on the WBC count, the CBC will establish if the patient has an infection and if the infection is bacterial or viral (Sokic-Milutinovic et al., 2022). The abdominal ultrasound will be used to visualize abdominal organs and identify if there is inflammation that could be contributing to the patient’s GI symptoms.

Differential Diagnoses

I would accept the GE diagnosis because it is consistent with the patient’s clinical features of diarrhea, generalized abdominal pain, nausea, low-grade fever, hyperactive bowel sounds, and abdominal tenderness. Nevertheless, I would reject LLQ pain as a diagnosis because it is a physical exam finding and does not fit the description of a medical diagnosis. The likely diagnoses for this case are:

Acute Viral Gastroenteritis

Viral GE is an acute, self-limiting diarrheal disease caused by viruses. The common causative viruses are rotavirus, norovirus, enteric adenovirus, and astroviruses. Clinical manifestations include anorexia, nausea, vomiting, watery diarrhea, abdominal pain/tenderness (mild to moderate), low-grade fever, dehydration, and hyperactive bowel sounds (Orenstein, 2020). Acute Viral GE is a presumptive diagnosis due to the patient’s clinical manifestations of nausea, diarrhea, abdominal pain, mild fever, abdominal tenderness on palpation, and hyperactive bowel sounds.

Ulcerative Colitis (UC)

UC is a chronic inflammatory and ulcerative GI disorder that occurs in the colonic mucosa and is characterized by bloody diarrhea. Clinical symptoms include mild lower abdominal pain, bloody diarrhea, and bloody mucoid stools. Systemic manifestations include anorexia, nausea, fever, malaise, anemia, and weight loss (Porter et al., 2020). The patient’s positive findings of nausea, diarrhea, abdominal pain, and mild fever, as well as a history of GI bleeding, makes UC a likely diagnosis.

Colonic Diverticulitis

Diverticulitis presents with inflammation of a diverticulum with the presence or absence of infection. Abdominal pain is the primary symptom of colonic diverticulitis. Patients present with LLQ abdominal pain and tenderness, which can sometimes be suprapubic and often have a palpable sigmoid. The abdominal pain is usually accompanied by fever, nausea, vomiting, and occasionally urinary symptoms (Swanson & Strate, 2018). Peritoneal signs like rebound and guarding can occur, especially with abscess or perforation. Colonic diverticulitis is a probable diagnosis based on nausea, mild fever, and LLQ pain findings.

Conclusion

The HPI in the objective portion should have described the characteristics of the abdominal pain and stated the onset, frequency, characteristics, and timing of diarrhea. A ROS should also be included with the patient’s positive and negative symptoms. The objective part should have detailed physical exam findings from a detailed abdominal exam. Diagnostic tests should include stool culture, CBC, and abdominal U/S. The likely diagnoses are Vital GE, Ulcerative colitis, and colonic diverticulitis.

 References

Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing.

Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1

Porter, R. J., Kalla, R., & Ho, G. T. (2020). Ulcerative colitis: Recent advances in the understanding of disease pathogenesis. F1000Research, 9, F1000 Faculty Rev-294. https://doi.org/10.12688/f1000research.20805.1

Sokic-Milutinovic, A., Pavlovic-Markovic, A., Tomasevic, R. S., & Lukic, S. (2022). Diarrhea as a Clinical Challenge: General Practitioner Approach. Digestive Diseases, 40(3), 282-289. https://doi.org/10.1159/000517111

Swanson, S. M., & Strate, L. L. (2018). Acute Colonic Diverticulitis. Annals of Internal Medicine, 168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010

The SOAP note’s 65-year-old Black American male patient arrives at the emergency room complaining of sporadic epigastric stomach ache that radiates to his back. When he went to the neighboring urgent care facility, PPIs were provided to him without providing any relief. The patient reported that the pain had been worse over the preceding few hours and he had vomited the afternoon when he finally went to the emergency department. He hasn’t had a fever, diarrhea, or any other signs often associated with stomach discomfort. The purpose of this paper is to demonstrate how to evaluate the offered subjective and objective data to determine the patient’s primary and differential diagnoses.

Subjective Portion

According to the OLDCARTS technique, the HPI lacks information on the kind, intensity, and aggravating and alleviating elements of the pain. In addition, there is no information on the color or consistency of vomit (Ball et al., 2019).The date of the HTN diagnosis and if the illness has been treated are missing from the PMH. This section ID also lacks information on previous hospitalizations and surgical histories. The dosage and frequency of metoprolol are not listed in the medication section.

The allergy section does not address allergies to food, the environment, or latex. A family history should include information on all first-degree relatives, including parents, grandparents, siblings, and their children. Add details on the person’s age, whether they’re living or deceased, and how they’re feeling. Any dead relatives’ age and method of death should also be mentioned. Age and any ailments should be mentioned if the person is still alive. It should also include a list of mental health issues including depression, addiction, and substance misuse.

Owing to the patient’s digestive issues, a comprehensive series of subjective GI system questions should be made, including Has the digestive illness continued for a considerable amount of time? Burning in the substernal area or the chest? Does your tummy hurt? struggling to swallow? Does swallowing hurt? Is it vomiting or nausea? abdominal bloating or distention? Have yellow skin (jaundice)? vomiting that is hemorrhagic (hematemesis)? stool that is dark or tarry? Scratched stools? Constipation? diarrhea or other alterations to bowel habits (Weledji, 2020). Patients do not receive Hepatitis A or B vaccines.

Objective Portion

The general assessment of the patient is not standardized. The vital signs section does not include the patient’s oxygen saturation or BMI. Every recent journey should be taken into account to assess GI problems related to travel. The physical exam of the skin should cover any skin changes, notably any yellowing that would suggest jaundice from cholestasis (Ball et al., 2019). Since changes in urine color can be an indication of cholestasis, a disorder in which the kidneys eliminate direct bilirubin from the serum, this topic belongs under the genitourinary area.

When a patient complains of stomach pain, nausea, and/or vomiting, the Gastrointestinal system should be thoroughly evaluated. The four quadrants of the abdomen should be evaluated using sonography, percussion, and palpation, as well as objective data from examining and assessing the abdomen for shape, scars, pigmentation, symmetry, and abnormal protrusions. Because cholestasis may be associated with pale-colored feces, stools should be inspected for color. Blood in the stool is investigated to rule out GI hemorrhage (Gallaher & Charles, 2022). Variations in appetite, nutrition, or food consumption must be taken into consideration in this assessment. For evaluating organ performance, it is essential to get the missing laboratory results.

Assessment Supported

A history of alcohol consumption supports the diagnosis of pancreatitis in the context of symptoms such as nausea, vomiting, and epigastric pain that radiates to the back (Hamm, 2021). Other tests to support pancreatitis diagnosis include elevated amylase and/or lipase levels that are 3 times higher than the upper limit of normal. Moreover, the CT ought to back up this diagnosis.

This diagnosis of AAA is unsupported because the patient in this case seems stable and lacks several of the crucial presenting symptoms. This diagnosis necessitates figuring out whether or not the AAA is raptured based on the symptoms that are now present. The majority of cases with AAA are undiagnosed and asymptomatic (Weledji, 2020). The initial imaging procedure necessary for this diagnosis, if the patient is not allergic to contrast or pregnant, is a CT scan with contrast.

A perforated ulcer is not supported by either subjective or objective facts. A burst peptic ulcer is identified by the classic trifecta of sudden onset of abdominal rigidity, tachycardia, and stomach distress. Both the patient’s heart rate and the abdomen are not tachycardic (Ball et al., 2019). A history of smoking is the only risk factor for PUD; the patient does not use any NSAIDS or steroids.

Diagnostic Tests

Many medical conditions can cause abdominal discomfort, and numerous tests may be necessary to identify the reason. In addition to a health history and physical exam, laboratory tests for blood, urine, stool, and enzymes may be utilized to aid in diagnosis. Abdominal abnormalities can also be found with imaging tests (Ball et al., 2019). Diagnostic tests will include an Electrocardiogram, which would disclose any aberrant cardiac findings and exclude ischemia due to the patient’s specific presentation of stomach discomfort.

Blood tests including the Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), and stool samples for magnesium and phosphorus are examples. To completely rule out an infection, they are crucial (Weledji, 2020). As the patient complains of frequently having diarrhea, the CMP would provide a current health status of the kidneys, liver, and electrolytes. Test for Liver Enzymes and Hepatic Function These examinations reveal how well the liver is working. This examination will demonstrate if the liver is successfully removing the body’s toxins, which may result in severe stomach discomfort. This is crucial because a portion of the liver can be found in the epigastric region 4.

Rejection or Acceptance

Unless more testing is done, I would not accept the diagnosis of AAA. While this patient complains of sporadic discomfort, his vital signs are stable, and even though individuals with AAA frequently arrive with tearing or ripping chest pain, this patient does not characterize his pain in such terms(Hafeez et al., 2018).

The major diagnosis is acute pancreatitis, which I accept. Hafeez et al. (2018) claim that acute pancreatitis may be diagnosed initially without the use of imaging and that the presence of stomach discomfort together with high lipase or amylase levels can help to confirm this diagnosis. Also, the patient has a known etiology such as alcoholism and hyperlipidemia (Grigorian et al., 2019).

Possible Conditions

Gastritis may be the cause of the abrupt onset of epigastric discomfort, nausea, and vomiting (Weledji, 2020). It could be brought on by elements like smoking and drinking, which LZ’s past demonstrates. The patient might additionally have gastritis as a result of stress, such as losing his job.

Ulcer perforation: For two days, the patient’s condition, such as stomach pain, grew worse. This is how ulcer perforation presents. From modest stomach aches to severe agony and tachycardia, it goes through many stages (Yamamoto et al., 2018). H. pylori infection or regular use of NSAIDs, which can damage the stomach lining, maybe the cause of this.

Cholecystitis causes the gallbladder to swell up. With nausea, purging, and fever as their accompanying symptoms, biliary colic is an increasing pain in the right upper quadrant that may progress to the back (Gallaher & Charles, 2022). Jaundice is evident depending on the degree of gallbladder neck obstruction. The attack typically happens after a large, fatty meal. The pain eventually develops into a little upper-right stomach discomfort or a nagging ache. Abdominal ultrasound can identify calcified gallstones, and elevated white blood cell counts in the test findings can help to make the diagnosis.

Conclusion

The 65-year-old Black American male patient is likely suffering from gastritis. This may be the cause of the abrupt onset of epigastric discomfort, nausea, and vomiting.In addition to the pertinent lab testing to rule out the differential diagnosis, additional findings that might assist corroborate this diagnosis have been noted above. Correct diagnosis is essential for fostering the creation of the most efficient care strategy.

References

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.ISBN: 9780323545389

Gallaher, J. R., & Charles, A. (2022). Acute Cholecystitis: A Review. JAMA, 327(10), 965–975. https://doi.org/10.1001/jama.2022.2350

Grigorian, A., Lin, M. Y., & de Virgilio, C. (2019). Severe epigastric pain with nausea and vomiting. Surgery, 227–237. https://doi.org/10.1007/978-3-030-05387-1_20

Hafeez, A., Karmo, D., Mercado-Alamo, A., & Halalau, A. (2018). Aortic dissection presenting as acute pancreatitis: Suspecting the unexpected. Case Reports in Cardiology, 2018, 1–4. https://doi.org/10.1155/2018/4791610

Hamm, R. G. (2021). Acute Pancreatitis: Causation, Diagnosis, and Classification Using Computed Tomography. Radiologic Technology, 93(2), 197CT219CT. https://pubmed.ncbi.nlm.nih.gov/34728586/

Weledji, E. P. (2020). An Overview of Gastroduodenal Perforation. Frontiers in Surgery, 7. https://doi.org/10.3389/fsurg.2020.573901

Yamamoto, K., Takahashi, O., Arioka, H., & Kobayashi, D. (2018). Evaluation of risk factors for perforated peptic ulcer. BMC Gastroenterology, 18(1). https://doi.org/10.1186/s12876-018-0756-4

Health care practitioners ought to assess the abdomen region thoroughly using the obtainable objective and subjective data. It is crucial that the data be thoroughly examined in order to get reliable results. Therefore, the purpose of this study is to look at specifics from a SOAP note of a 65-year-old man who has been complaining of intermittent epigastric stomach pain that extends to his back for two days. We’ll examine the submitted subjective and objective data, and we’ll add extra information to make it more complete. Additionally, recommended diagnostic tests will be provided. Later, a more comprehensive differential diagnosis is going to be presented (Dains & Scheibel, 2019).

Analysis of Subjective Data

            When gathering subjective data on a patient experiencing epigastric stomach pain, one must make sure they have properly recorded the necessary specifics that will help them limit down the possible differential diagnoses to one. The first one, which is the history of the present sickness (HPI), was well-received. It began with the major complaint, “My stomach has been hurting for the past two days.” The date, which was reported to have occurred two days ago, and the features of the pain, such as whether it is radiating from the history supplied, it was mentioned that the pain radiates to the back should then be included in the HPI (Dains & Scheibel, 2019).

            The exact site of the pain ought to be mentioned; based on the information provided, it was determined that it was in the epigastric area. Analysis of system reviews that concentrate on the abdomen region can be used to locate the location. This would then indicate that the discomfort is emanating from the epigastric area and is localized there. The frequency of the pain, which was suggested to be intermittent, should be included in the specifics. As was reported, the patient visited the hospital and was prescribed PPIs with no alleviation. Details regarding whether or not the patient sought care as well as the interventions made should be available. If the patient had further symptoms that suggested he had vomited, that should be noted (Dains & Scheibel, 2019).

            1. It’s important to identify and rate additional data, such as the patient’s pain scale. It is important to understand how the patient’s regular activities may be affected (Dains & Scheibel, 2019).

            2. Additionally, information about the patient’s attempts to manage it independently at home should be made available (Dains & Scheibel, 2019).

3. As the stomach is the problem, information on the patient’s diet, including the previous meal, salt intake, changes in hunger, and what his diet consists of, should be gathered (Dains & Scheibel, 2019).

            4. The assessment of systems should include the gastrointestinal system, and details such changes in bowel habits should be noted (Dains & Scheibel, 2019).

            5. In addition to the information presented, social history should also cover coffee consumption, illegal drug use, and the existence of stresses. It’s also important to determine whether he has access to healthcare. Additionally, the frequency, amount, and effectiveness of any medications he takes at home, as well as the use of any other prescription drugs and supplements, should all be noted (Dains & Scheibel, 2019).

            6. If the patient changed his lifestyle as a result of being diagnosed with HTN and if he checks his blood pressure, he should mention it. Additionally, details like prior hospitalizations should be disclosed (Dains & Scheibel, 2019).

            Past medical history ought to be taken into account, such as the diagnosis of hypertension (HTN) and the prescription drugs he is currently taking, metoprolol, for that condition. The presence of allergies, which were disclosed and reported to be absent, should be known, and it should be determined if the patient is keeping up with their immunizations. Information on the family history of HTN, GERD, and hyperlipidemia should be available (Dains & Scheibel, 2019).

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

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

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.

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?
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.

By Day 7 of Week 6

Submit your Lab Assignment. 

submission information

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1. To submit your completed assignment, save your Assignment as WK6Assgn1+last name+first initial.
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.