Lab Assignment: Assessing the Abdomen
ABDOMINAL ASSESSMENT
Subjective:
Chief Complaint: \”My stomach has been hurting for the past two days.\”
HPI: 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 PPIs 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
Family History: 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:
Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10â€; 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
To Prepare
Review the Episodic note case study your instructor provides you for this weeks Assignment. Episodic note case study.
With regard to the Episodic note case study provided:
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Analyze an Episodic note case study. Write this up as a narrative.
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. REFERENCES MUST BE WITHIN 1 TO 5 YEARS.
DO NOT USE ANOTHER STUDENTS WORK. SAFE ASSGN WILL DETECT IF ANOTHER STUDENT WORK WAS USED.
Advanced Health Assessment and Diagnostic Reasoning
Student’s Name
Institutional Affiliations
Advanced Health Assessment and Diagnostic Reasoning
Subjective Portion
Collecting the medical history of a patient is a crucial component of care. The reason is that it helps the healthcare provider to understand how the patient is feeling and gather crucial data about health risks that might be linked with current symptoms (Flugelman, 2021). The subjective portion of the note lacks data for the review of systems. When collecting medical history, the healthcare provider should review body systems by asking the patient about how he or she is feeling (Bickley et al., 2020). Additional information to be added to the subjective portion of the note includes data as reported by the patient for major body systems including the head, eyes, ears, nose, and throat (HEENT), neck, pulmonary, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurologic, psychiatric, endocrine, and hematologic systems (Dains et al., 2019).
Objective Portion
The objective portion of the note is a section of a SOAP note where the clinician documents the physical exam results conducted on the patient. This data helps the clinician to determine the body organs and symptoms that have been affected by the disease (Bickley et al., 2020). The information included in the objective portion of the given note is insufficient to guide the clinician to make the best decision regarding the patient’s possible diagnosis. Additional information to be included in this section include physical exam results covering the patient’s general appearance, HEENT examination, neck, breast, chest, musculoskeletal, genitourinary, neurologic, and results of laboratory tests conducted (Dains et al., 2019).
Whether Assessment is Supported by the Subjective and Objective Information
Some of the assessments are supported by the subjective and objective portions of the note but not others. According to Dains et al. (2019), a patient’s diagnosis should be supported by both the subjective and objective data collected during history taking and physical examination respectively. The patient’s possible conditions given under the assessment section of the note include abdominal aortic aneurysm (AAA), perforated ulcer, and pancreatitis. The primary symptoms in patients with abdominal aortic aneurysm (AAA) include low blood pressure, abdominal pain, back pain, and abdominal pulse (Al-Zoubi et al., 2021). Some of the data is present in both the subjective and objective portions of the given note. Intermittent epigastric abdominal pain supports the presence of a perforated ulcer. However, there is no objective data such as positive laboratory tests for Helicobacter pylori (Chung & Shelat, 2017). Intermittent epigastric abdominal pain that radiates to the back (subjective), vomiting (subjective), and abdominal tenderness (objective) support the presence of pancreatitis (Mayo Clinic, 2022). Collecting additional subjective and objective data can help to reveal the actual diagnosis.
Appropriate Diagnostic Tests
The clinician should order a number of tests to help rule out some conditions and make an accurate diagnosis. The appropriate diagnostic tests to be conducted on the patient include a blood test to detect Helicobacter pylori, endoscopy to assess the internal structures of the digestive system, abdominal ultrasound to detect pancreas inflammation, stool tests to examine pancreatic functioning, and radiologic tests including abdominal x-rays, abdominal computed tomography scan, and abdominal magnetic resonance imaging to assess structural damage of the abdomen (Al-Zoubi et al., 2021; Chung & Shelat, 2017; Mayo Clinic, 2022).
Reject or Accept the Current Diagnosis
The clinician should accept the current diagnosis but should consider pancreatitis as the primary diagnosis. The reason is that both subjective and objective data support the presence of pancreatitis. However, the clinician should complete the recommended diagnostic tests to gather additional data that can lead to the identification of the most accurate diagnosis (Dains et al., 2019).
Three Possible Conditions
The three possible conditions that can be considered as the patient’s diagnoses and their explanations are as detailed below;
- Pancreatitis (primary diagnosis): Common symptoms include pain in the upper abdomen radiating to the back, abdominal tenderness, fever, and vomiting (Mayo Clinic, 2022).
- Abdominal Aortic Aneurysm (AAA): Patients usually present with low blood pressure, abdominal pain, back pain, and pulse in the abdomen (Al-Zoubi et al., 2021).
3. Perforated Ulcer: Clinical manifestations include intermittent epigastric pain, blotting, nausea, and a positive test for Helicobacter pylori (Chung & Shelat, 2017).
References
Al-Zoubi, N. A., Mahafdah, M. R., & Albawaih, O. (2021). Chronic contained rupture of the abdominal aortic aneurysm. Open Access Emergency Medicine: OAEM, 13, 439–443. https://doi.org/10.2147/OAEM.S327922
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13th ed. Philadelphia: Wolters Kluwers.
Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer – an update. World Journal of Gastrointestinal Surgery, 9(1), 1–12. https://doi.org/10.4240/wjgs.v9.i1.1
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Flugelman, M. Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6), Doc109. https://doi.org/10.3205/zma001505
Mayo Clinic. (2022). Pancreatitis. mayoclinic.org/diseases-conditions/pancreatitis/symptoms-causes/syc-20360227#:~:text=Pancreatitis%20is%20inflammation%20of%20the,body%20processes%20sugar%20(glucose).