NURS 6512 Week 6 Assignment 1: 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.
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.
- 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 the 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.
By Day 7 of Week 6
Assessing the Abdomen Sample Paper
The gastrointestinal system is a complex system with several hollow and non-hollow organs. Structures within the abdomen include the stomach, small and large intestine, liver, pancreas, gall bladder, spleen, and appendix (Frumkin & Delahanty, 2018). A disease process to any of the organs is always stressful to patients and therefore must be sought. Symptoms related to GIT are non-specific and may either represent a problem within the GIT or a systemic problem that manifests in this system.
Diagnosis and choosing therapeutic intervention are major challenges due to the complexity of the system (Arasaradnam et al., 2018). Children mostly will present to the emergency department with abdominal pain. Others may require admission while others will be treated and go home. This paper will talk about history, physical exams, laboratory tests, and differential diagnosis for the patient in the case study.
Proper diagnosis of abdominal conditions requires a detailed history, physical examination, and ordering relevant laboratory tests (Leung et al., 2019). History is built from the chief complaint to help in coming up with differentials. In this case the patient presents with abdominal pains and diarrhea. Pain needs to be probed further to help in assessing its origin and help in planning for therapy.
Several questions will be asked regarding the abdominal pain. The onset of the pain should be probed to assess if either it was gradual or sudden onset (Frumkin & Delahanty, 2018). The exact location of the pain should be known. Location of pain should be described according to the locality as per the division of the abdomen into four major quadrants.
Different locations refer to different conditions. The characteristics of the pain should also be sought. It is necessary to identify if the pain is colicky, non-colicky, burning, stabbing, dull, boring, tearing, squeezing, or pricking. Variant pain characteristics denote different conditions.
Assessing the pain radiation is important in identifying the anatomic structures involved (Narayanan, Reddy & Marsicano, 2018). Pain may primarily from the abdomen and radiates to the back or other structures, or the pain may emanate from other structures such as the heart and lungs be referred to the abdomen. Timing of the pain is also important to identify the specific time that the pain occurs.
Associated symptoms such as vomiting, nausea, and fever should be sought. In case of vomiting, then the frequency, amount, and content of the vomitus must be described. Additionally, the relieving and aggravating factors must be assessed. Positions that made the pain worse or better must be described as different structures that will present with various aggravating and relieving factors.
Diarrhea is also another symptom that should be sought. The onset, frequency, volume, color, and odor of diarrhea are important (Arasaradnam et al., 2018). Large volume diarrhea is associated with infections of the small intestine. Assessing the frequency and the amount of diarrhea helps identify if the patient is at risk of hypovolemia and dehydration. Additionally, knowing the last meal eaten before the events is important. Finally, assessing if any of the family members also present with the symptoms will help rule out food poisoning.
According to Jacobsen et al. (2020), an examination helps build the findings from the history and helps in coming up with a diagnosis. The skin should be sought to identify the level of dehydration. Skin pinch can be used to achieve this objective. An abdominal exam should include observation, palpation, percussion, and auscultation (Frumkin & Delahanty, 2018).
Observation should include checking for distension or extended abdominal veins. Palpation for organomegaly helps identify the extent of organs. Percussion helps in assessing the filling of abdominal gasses (Jacobsen et al., 2020). General examination should include checking for any discomfort, diaphoresis, or lethargy.
Testing will include a blood test, stool tests, and imaging to help in coming up with the diagnosis. A blood test will include complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive proteins (CRP) (Leung et al., 2019). Assessing the level of neutrophils, lymphocytes, eosinophils, platelets, and red blood cells is assessed.
Neutrophilia represents an active infection of bacterial origin. Lymphocyte increase indicates viral infection while eosinophil increase may be attributed to parasitic infection. An increase in ESR and CRP indicates an active infection.
Stool tests include microscopy for ova and cyst. As Fehnel et al. (2017) notes, this helps in identifying the specific organism that causes abdominal pain or diarrhea. Cysts or ova of entamoeba, salmonella or giardia lamblia among other organisms can be identified. Fecal leukocytes can also be carried out to determine the rate of inflammation. Helicobacter pylori antigen test to identify the presence of H. pylori that causes peptic ulcers.
Imaging tests include upper GI endoscopy and ultrasound (Narayanan et al., 2018). GI endoscopy will help examine the intestine and could help in examining the source of bleeding the patient suffered 4 years ago. Abdominal ultrasound helps in assessing the abdomen to identify any abnormalities. These tests combined but not in isolation can help make the diagnosis.
Diagnosis and Differential Diagnosis
From the assessment, diagnosis of gastroenteritis and lower left quadrant pain a preliminary diagnosis (Leung et al., 2019). This is reasonable based on the history and physical examination. gastroenteritis is based on a history of abdominal pain and diarrhea. Physical findings revealed tenderness on the left lower quadrants revealing pain. This tenderness reveals the likelihood of inflammation of the descending colon and sigmoid colon.
The differential diagnosis of consideration includes peptic ulcer disease, acute gastritis, irritable bowel syndrome, colitis, and acute food poisoning (Frumkin & Delahanty, 2018). Peptic ulcer disease results from hyperproduction of hydrochloric acid that causes inflammation of the stomach. This patient is likely having PUD due to a history of alcohol consumption and GI bleeding four years ago. According to Narayanan et al. (2018), H. pylori is the leading cause of PUD while alcohol consumption is the second most cause.
Acute gastritis is supported by diarrhea, abdominal pain that is reducing in severity and considering it is only for three days. Pain is due to inflammation that may be caused by bacterial infections. Acute gastritis may also be exacerbated by alcohol consumption.
Irritable bowel syndrome is also a possible differential diagnosis (Fehnel et al., 2017). There is no known cause of abdominal pain or diarrhea that is identified as a precipitating factor. The presence of abdominal pain and diarrhea for three days makes this diagnosis feasible. Other features of IBS include constipation, bloating, gas, and cramping.
Acute food poisoning is also considered. Finding the history of the last meal eaten and finding out if other people who used the meal are also affected will be useful in causing acute poisoning. The presence of acute abdominal pain and diarrhea are also making the diagnosis likely. Alcohol consumption may also cause poisoning (Leung et al., 2019). Colitis on the other hand is also possible due to diarrhea and abdominal pain.
The patient also has some conditions including hypertension and diabetes. These conditions also predispose to the acute abdomen (Leung et al., 2019). Diabetic ketoacidosis can also present with acute pain. This may result from uncontrolled diabetes or not taking medications regularly. Additionally, the medications also cause side effects that may present as abdominal pain and diarrhea.
Abdominal pain and diarrhea are common presentations to most patients. Carrying out focused history, physical exams, and laboratories that are useful in making a diagnosis. Assessment of this patient revealed gastroenteritis and left lower quadrant pain. The differential diagnosis includes PUD, colitis, acute gastritis, IBS, and acute food poisoning. The underlying conditions may also predispose the patient to develop the symptoms.
- Arasaradnam, R. P., Brown, S., Forbes, A., Fox, M. R., Hungin, P., Kelman, L., Major, G., O’Connor, M., Sanders, D. S., Sinha, R., Smith, S. C., Thomas, P., & Walters, J. R. F. (2018). Guidelines for the investigation of chronic diarrhea in adults: British Society of Gastroenterology, 3rd edition. Gut, 67(8), 1380–1399. https://doi.org/10.1136/gutjnl-2017-315909
- Fehnel, S. E., Ervin, C. M., Carson, R. T., Rigoni, G., Lackner, J. M., Coons, S. J., & Critical Path Institute Patient-Reported Outcome Consortium’s Irritable Bowel Syndrome Working Group. (2017). Development of the diary for irritable bowel syndrome symptoms to assess treatment benefit in clinical trials: Foundational qualitative research. Value in Health: The Journal of the International Society for Pharmacoeconomics and Outcomes Research, 20(4), 618–626. https://doi.org/10.1016/j.jval.2016.11.001
- Frumkin, K., & Delahanty, L. F. (2018). Peripheral neuropathic mimics of visceral abdominal pain: Can physical examination limit diagnostic testing? The American Journal of Emergency Medicine, 36(12), 2279–2285. https://doi.org/10.1016/j.ajem.2018.08.042
- Jacobsen, A. P., Khiew, Y. C., Murphy, S. P., Lane, C. M., & Garibaldi, B. T. (2020). The modern physical exam – A transatlantic perspective from the resident level. Teaching and Learning in Medicine, 32(4), 442–448. https://doi.org/10.1080/10401334.2020.1724792
- Leung, A. K. C., Leung, A. A. M., Wong, A. H. C., & Hon, K. L. (2019). Travelers’ diarrhea: A clinical review. Recent Patents on Inflammation & Allergy Drug Discovery, 13(1), 38–48. https://doi.org/10.2174/1872213X13666190514105054