Sample Answer for NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen Included After Question
NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?
Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.
This week, you will explore how to assess the abdomen and gastrointestinal system.
NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
Learning Objectives – Week 6: Assessment of the Abdomen and Gastrointestinal System
Students will:
Evaluate abnormal abdomen and gastrointestinal findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
Photo Credit: Hill Creek Pictures/UpperCut Images/Getty Images
Learning Resources – Week 6: Assessment of the Abdomen and Gastrointestinal System
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 4, “Vital Signs and Pain Assessment” (pp. 50-63)This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.
Chapter 17, “Abdomen” (pp. 370-415)In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment on the abdomen.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 3, “Abdominal Pain” (pp. 11-32)This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.
Chapter 10, “Constipation” (pp. 110-117)The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.
Chapter 12, “Diarrhea” (pp. 133-147)In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.
Chapter 29, “Rectal Pain, Itching, and Bleeding” (pp. 344-356)This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 10, “Admitting a Patient to the Hospital” (pp. 217-238)
Note: Download this Adult Examination Checklist and Abdomen Physical Exam Summary to use during your practice abdominal examination.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for abdominal assessment. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Abdominal Assessment was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Abdomen. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Abdomen Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
University of Virginia. (n.d.). Introduction to radiology: An online interactive tutorial. Retrieved from http://www.med-ed.virginia.edu/courses/rad/index.html. This website provides an introduction to radiology and imaging. For this week, focus on gastrointestinal radiology.
Required Media
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7, and 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.
Optional Resources- Week 6: Assessment of the Abdomen and Gastrointestinal System
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)This chapter explores the health assessment processes for the abdomen, perineum, anus, and rectosigmoid. This chapter also examines the symptoms of many conditions in these areas.
Chapter 10, “The Urinary System” (pp. 528–540)In this chapter, the authors provide an overview of the physiology of the urinary system. The chapter also lists symptoms and conditions of the urinary system. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System.
NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
NURS 6512 Assesment 1: 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 CAT scan. The CAT 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 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.
Abdominal Assessment
SUBJECTIVE:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
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.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
OBJECTIVE:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperctive bowel sounds, pos pain in the LLQ
Diagnostics: None
NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System
ASSESSMENT:
Left lower quadrant pain
Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
To prepare:
With regard to the SOAP 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.
To complete:
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 3 different references from current evidence based literature.
A Sample Answer For the Assignment: NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
Title: NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
The SOAP note concerns a 47-year-old white man with chief complaints of abdominal pain and diarrhea. He has had generalized abdominal pain for three days but has not taken any meds to relieve the pain. He reports that the pain was initially at 9/10 but has reduced to 5/10, and he cannot eat due to ensuing nausea. His medical history is positive for
hypertension, DM, and GI bleeding. GI exam findings include a soft abdomen, hyperactive bowel sounds, and LLQ pain. The purpose of this paper is to analyze the SOAP note, identify appropriate diagnostic tests, and discuss likely diagnoses.
Subjective Portion
The SOAP note’s HPI describes the abdominal pain, including the onset, location, associated symptoms, and severity of pain. Nevertheless, the HPI should have given an additional description of the abdominal pain, particularly the duration of the abdominal pain, timing (before, during, or after meals), and frequency. In addition, the characteristics of the abdominal pain should be included describing if the pain is sharp, crampy, dull, colicky, diffuses, constant, or radiating (Sokic-Milutinovic et al., 2022). In addition, the HPI should have included the exacerbating and alleviating factors for the abdominal pain and to what level the alleviating factors relieve the pain. Furthermore, the HPI has described only the abdominal pain leaving out diarrhea. It should describe diarrhea, including the onset, timing, frequency, characteristics of the stools (watery, mucoid, bloody, greasy, or malodorous), and relieving and aggravating factors.
The subjective part should have included the patient’s immunization status with a focus on the last Tdap, Influenza, and COVID shots and surgical history. The social history has scanty information and should have included the patient’s education level, occupation, current living status, hobbies, exercise and sleep patterns, dietary habits, and health promotion interventions (Gossman et al., 2020). Lastly, a review of systems (ROS) is mandatory for a SOAP note. Thus, the SOAP note should have a ROS that indicates the pertinent positive and negative symptoms in each body system, which helps identify other symptoms the patient has not reported in the HPI.
Objective Portion
The objective part misses critical information like the findings from the general assessment of the patient, which should include the client’s general appearance, personal hygiene, grooming, dressing, speech, body language, and attitude towards the clinician. In addition, findings from a detailed abdominal exam should have been provided. For instance, it should have inspection findings, including the abdomen’s pigmentation, respiratory movements, symmetry, contour, and presence of scars. Additional auscultation findings that should be indicated include the presence of friction ribs, vascular sounds, and venous hum. It should also have exam findings from palpation and percussion, including abdominal tenderness, masses, organomegaly, guarding, or rebound tenderness (Sokic-Milutinovic et al., 2022). Besides, the liver span and spleen position should be indicated.
Assessment
The assessment findings identified in the SOAP note are Left lower quadrant (LLQ) pain and gastroenteritis (GE). LLQ pain is supported by subjective findings of abdominal pain and LLQ tenderness on exam. GE is consistent with subjective data of diarrhea, abdominal pain, and nausea and objective data of low-grade fever of 99.8 and hyperactive bowel sounds, which are classic symptoms.
Diagnostic Tests
The appropriate diagnostic tests for this patient are stool culture, complete blood count (CBC), and abdominal ultrasound. A stool culture is crucial to look for ova and cyst, which will help establish the causative agent for diarrhea and guide the treatment plan. Based on the WBC count, the CBC will establish if the patient has an infection and if the infection is bacterial or viral (Sokic-Milutinovic et al., 2022). The abdominal ultrasound will be used to visualize abdominal organs and identify if there is inflammation that could be contributing to the patient’s GI symptoms.
Differential Diagnoses
I would accept the GE diagnosis because it is consistent with the patient’s clinical features of diarrhea, generalized abdominal pain, nausea, low-grade fever, hyperactive bowel sounds, and abdominal tenderness. Nevertheless, I would reject LLQ pain as a diagnosis because it is a physical exam finding and does not fit the description of a medical diagnosis. The likely diagnoses for this case are:
Acute Viral Gastroenteritis
Viral GE is an acute, self-limiting diarrheal disease caused by viruses. The common causative viruses are rotavirus, norovirus, enteric adenovirus, and astroviruses. Clinical manifestations include anorexia, nausea, vomiting, watery diarrhea, abdominal pain/tenderness (mild to moderate), low-grade fever, dehydration, and hyperactive bowel sounds (Orenstein, 2020). Acute Viral GE is a presumptive diagnosis due to the patient’s clinical manifestations of nausea, diarrhea, abdominal pain, mild fever, abdominal tenderness on palpation, and hyperactive bowel sounds.
Ulcerative Colitis (UC)
UC is a chronic inflammatory and ulcerative GI disorder that occurs in the colonic mucosa and is characterized by bloody diarrhea. Clinical symptoms include mild lower abdominal pain, bloody diarrhea, and bloody mucoid stools. Systemic manifestations include anorexia, nausea, fever, malaise, anemia, and weight loss (Porter et al., 2020). The patient’s positive findings of nausea, diarrhea, abdominal pain, and mild fever, as well as a history of GI bleeding, makes UC a likely diagnosis.
Colonic Diverticulitis
Diverticulitis presents with inflammation of a diverticulum with the presence or absence of infection. Abdominal pain is the primary symptom of colonic diverticulitis. Patients present with LLQ abdominal pain and tenderness, which can sometimes be suprapubic and often have a palpable sigmoid. The abdominal pain is usually accompanied by fever, nausea, vomiting, and occasionally urinary symptoms (Swanson & Strate, 2018). Peritoneal signs like rebound and guarding can occur, especially with abscess or perforation. Colonic diverticulitis is a probable diagnosis based on nausea, mild fever, and LLQ pain findings.
Conclusion
The HPI in the objective portion should have described the characteristics of the abdominal pain and stated the onset, frequency, characteristics, and timing of diarrhea. A ROS should also be included with the patient’s positive and negative symptoms. The objective part should have detailed physical exam findings from a detailed abdominal exam. Diagnostic tests should include stool culture, CBC, and abdominal U/S. The likely diagnoses are Vital GE, Ulcerative colitis, and colonic diverticulitis.
References
Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing.
Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1
Porter, R. J., Kalla, R., & Ho, G. T. (2020). Ulcerative colitis: Recent advances in the understanding of disease pathogenesis. F1000Research, 9, F1000 Faculty Rev-294. https://doi.org/10.12688/f1000research.20805.1
Sokic-Milutinovic, A., Pavlovic-Markovic, A., Tomasevic, R. S., & Lukic, S. (2022). Diarrhea as a clinical challenge: General practitioner approach. Digestive Diseases, 40(3), 282-289. https://doi.org/10.1159/000517111
Swanson, S. M., & Strate, L. L. (2018). Acute colonic diverticulitis. Annals of Internal Medicine, 168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010
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