Assessing The Abdomen
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.
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
· Skin: Intact without lesions, no urticaria
· Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
· Diagnostics: US and CTA
Assessment:
1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis
.
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