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.

By Day 7 of Week 6

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Expert Answer and Explanation

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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