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

Lab Assignment: Assessing the Abdomen

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.

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 conditions.

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.

CASE STUDY

This week we will embrace on the Assessment of the Abdomen and Gastrointestinal System.

One of your assignments for this week is to complete an analysis of the SOAP note provided. Please approach it as a narrative so that you will be able to correctly explain your analysis. Please review the instructions under learning resources on how to do this assessment

ABDOMINAL ASSESSMENT-SOAP Data

Subjective:

CC: “My stomach hurts I have diarrhea, and nothing seems to help.”

HPI: JR, 47 yo 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 afterward.

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

The second assignment for this week is your midterm examination and it is due by Day 7 and will end promptly on the end date and time. Plan accordingly as IT or faculty are not allowed to reset exams. The exam review guide for the midterm can be found in the “Resources” section for this week. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.

This exam will be on topics covered in weeks 1, 2, 3, 4, 5, and 6. This exam is timed with a limit of two hours for completion. When time is up, the exam will automatically submit. If you try to access the exam after the due date, it will not be accessible.

Lab Assignment: Assessing the Abdomen

Nurses should know the processes to follow when examining their patients to determine the illness affecting them. McDonald et al. (2018) note that nurses should collect subjective and objective data when assessing their patients in a move to produce an accurate diagnosis. In this assignment, a case study will be analyzed, and additional subjective and objective data to be included in the diagnosis process will be determined.

Additional Subjective Data

According to Garzaro et al. (2019), subjective data is the data given by the client. It is the patient’s point of view about the disease ailing him or her. Subjective data can include the client’s perceptions, feelings, and concerns. In the case study, the nurse collected much vital subjective information. However, the following missing information can make the data more useful during diagnosis. The nurse should have asked whether the patient uses alcohol or not. Lifestyle information could also help in planning treatment for the patient. Therefore, the nurse should have been asked if he is involved in regular physical activities, eats a healthy diet, uses seat belts when traveling, or uses a cell phone while driving. Information about his activities during leisure, his profession, and vaccination history can also help build the patient’s subjective data. The patient’s grandparents’ health history can also be vital to determine if he risks having cancer. Information about previous hospitalization and surgeries can also be vital when collecting subjective data.

Additional Objective Data

Objective data is the information collected through diagnostic and laboratory testing, observation, and physical examination (Garzaro et al., 2019). Various information could be included in this section to build objective data. Observation of how the patient walks could tell the severity of the pain he feels. Patients with abdominal pain often walk while holding their abdomen. During palpation, the nurse should record if the patient has any scars, vascular changes, protrusions, or striae. Also, information about the general contour of the abdomen can improve objective data. The location and size of intra-abdominal organs should also be recorded as objective data. The internal organs should be evaluated during physical examination and results recorded to show the source of pain. The size of the patient’s liver can also be used to build objective data. Apart from physical examination data, information about diagnostic tests should be included in the objective data section. Such tests include a fluid wave test for ascites and digital rectal examination to assess the rectum, colorectal cancer, fecal impaction, and prostate.

Is the Assessment Supported by the Objective and Subjective Data?

The primary diagnosis for this case is left lower guardant pain caused by gastroenteritis. According to Bartsch et al. (2016), gastroenteritis is a viral infection that causes inflammation and irritation of the stomach and the intestines. Some of this condition symptoms include vomiting, nausea, cramping, stomach, headache, and diarrhea. The objective and subjective data were used to support the assessment. For instance, the patient noted in an interview that she was her stomach was aching, and she had diarrhea, and all these are signs of gastroenteritis. Fever is also a sign of the disease. The patient’s objective data conformed he had a high fever when temp showed 99.8 F. The patient’s abdominal examination showed that he had soft, hyperactive bowel sound and pain in the LLQ, which as shows that he has gastroenteritis that causes pain in the LLQ as indicated in the assessment. However, laboratory and diagnostics results have not been used in the assessment because they are not present in the case.

Appropriate Diagnostic Tests

The main diagnostic test for this case is a rapid stool test. Bartsch et al. (2016) note that a rapid stool test can be ordered to determine whether the patient has norovirus or rotavirus in the stomach area. However, to determine viral infections, the stool sample can be taken to a laboratory and results produced after two days or so. Apart from the rapid stool test, a fluid wave test should be conducted to determine the health of the patient’s rectum and other neighboring organs. A digital rectal examination is another test that should be conducted in this case. The tool results will show whether the patient has prostate cancer colorectal cancer, rectum cancer, or any other disease that can cause pain in the abdomen. The results of the tests will be compared with the provided data and a more accurate diagnosis made.

Rejection/Accepting the Current Diagnosis

I would not reject the current diagnosis because both subjective and objective data confirm that the patient has gastroenteritis.

Differential Diagnosis 

Apart from gastroenteritis, other diagnoses include the following. First, inflammatory bowel disease. Huang et al. (2017) note that this condition causes pain on the abdomen by causing inflammation of the large intestines’ walls. The second diagnosis is intussusception. This condition causes pain in the abdomen by making the small intestines to obstruct (Marsicovetere et al., 2017). The last diagnosis is sepsis. The condition can cause inflammation in the stomach, which leads to pain (Force, 2018).

Conclusion

The patient is most likely to suffer gastroenteritis because the disease causes all the symptoms he highlighted. The other three diagnoses include inflammatory bowel disease, intussusception, and sepsis.

References

Bartsch, S. M., Lopman, B. A., Ozawa, S., Hall, A. J., & Lee, B. Y. (2016). Global economic burden of norovirus gastroenteritis. PloS one, 11(4), e0151219. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151219

Force, I. S. T. (2018). Infectious Diseases Society of America (IDSA) position statement: why IDSA did not endorse the surviving sepsis campaign guidelines. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, 66(10), 1631. doi: 10.1093/cid/cix997

Garzaro, M., Dell’Era, V., Riva, G., Raimondo, L., Pecorari, G., & Valletti, P. A. (2019). Endoscopic versus conventional septoplasty: objective/subjective data on 276 patients. European Archives of Oto-Rhino-Laryngology, 276(6), 1707-1711. https://link.springer.com/article/10.1007/s00405-019-05393-w

Huang, H., Fang, M., Jostins, L., Mirkov, M. U., Boucher, G., Anderson, C. A., … & D’Amato, M. (2017). Fine-mapping inflammatory bowel disease loci to single-variant resolution. Nature, 547(7662), 173-178. https://www.nature.com/articles/nature22969

Marsicovetere, P., Ivatury, S. J., White, B., & Holubar, S. D. (2017). Intestinal intussusception: etiology, diagnosis, and treatment. Clinics in colon and rectal surgery, 30(01), 030-039. DOI: 10.1055/s-0036-1593429

McDonald, E. W., Boulton, J. L., & Davis, J. L. (2018). E-learning and nursing assessment skills and knowledge–An integrative review. Nurse education today, 66, 166-174. https://doi.org/10.1016/j.nedt.2018.03.011

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