Assessing the Abdomen<\/strong><\/p>\nA woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer\u2014the real cause of the cramping.<\/p>\n
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.<\/p>\n
In this assignment, you will analyze a SOAP 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.<\/p>\n
Abdominal Assessment<\/strong><\/p>\nSUBJECTIVE:<\/strong><\/p>\n\n- CC: \u201cMy stomach hurts, I have diarrhea and nothing seems to help.\u201d<\/li>\n
- 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 afterwards.<\/li>\n
- PMH: HTN, Diabetes, hx of GI bleed 4 years ago<\/li>\n
- Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs<\/li>\n
- Allergies: NKDA<\/li>\n
- FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD<\/li>\n
- Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)<\/li>\n<\/ul>\n
OBJECTIVE:<\/strong><\/p>\n\n- VS: Temp 99.8; BP 160\/86; RR 16; P 92; HT 5\u201910\u201d; WT 248lbs<\/li>\n
- Heart: RRR, no murmurs<\/li>\n
- Lungs: CTA, chest wall symmetrical<\/li>\n
- Skin: Intact without lesions, no urticaria<\/li>\n
- Abd: soft, hyperctive bowel sounds, pos pain in the LLQ<\/li>\n
- Diagnostics: None<\/li>\n<\/ul>\n
ASSESSMENT:<\/strong><\/p>\n\n- Left lower quadrant pain<\/li>\n
- Gastroenteritis<\/li>\n
- PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.<\/li>\n<\/ul>\n
To prepare:<\/strong><\/p>\nWith regard to the SOAP note case study provided:<\/p>\n
\n- Review this week\u2019s Learning Resources, and consider the insights they provide about the case study.<\/li>\n
- Consider what history would be necessary to collect from the patient in the case study.<\/li>\n
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\u2019s condition. How would the results be used to make a diagnosis?<\/li>\n
- Identify at least five<\/strong> possible conditions that may be considered in a differential diagnosis for the patient.<\/li>\n<\/ul>\n
To complete:<\/strong><\/p>\n\n- Analyze the subjective portion of the note. List additional information that should be included in the documentation.<\/li>\n
- Analyze the objective portion of the note. List additional information that should be included in the documentation.<\/li>\n
- Is the assessment supported by the subjective and objective information? Why or Why not?<\/li>\n
- What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis?<\/li>\n<\/ul>\n
\n- 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 3 different references from current evidence based literature.<\/li>\n<\/ol>\n \n