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.
· 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)
· 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, hyperactive bowel sounds, pos pain in the LLQ
· Diagnostics: None
· Left lower quadrant pain
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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.
Running head: ASSESSING THE ABDOMEN
Running head: Assessing the Abdomen
Assessing the Abdomen
NURS 6512: Advanced Health Assessment & Diagnostic Reasoning
Assessing the Abdomen
As advanced practitioners, we will treat many patients with gastrointestinal alterations. Due to the high potential for misdiagnosis, determining the precise cause of abdominal pain can be time-consuming and challenging. As nurse practitioners, we must thoroughly assess our patients for both subjective and objective data to better diagnose conditions of the abdomen. The purpose of this paper is to analyze a SOAP note with abnormal findings of a patient that presented to a clinical setting and determine what additional diagnostic tests should be utilized and three differential diagnosis’ for this condition.
: “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.
: HTN, Diabetes, hx of GI bleed 4 years ago.
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional ETOH, Married, 3 children (1girl, 2 boys)
Most healthcare providers use a customary organization of information from the interview and physical examination. Health care facilities often incorporate the information in standardized forms or templates such as the SOAP (Subjective, Objective, Assessment, Plan) template. Subjective data is the information, including the absence or presence of pertinent symptoms, that the patient tells you (Ball, et al., 2015). Additional questions that could be asked would include: Have you ever had this problem before? How many bowel movements are you having a day? Is there any noticeable blood in the stool? What color are the stools? Where is the exact location of your pain? Describe the pain. Is it sharp or dull? Is it constant or does it come and go? Does the pain go away by passing gas? Be sure to record the severity of pain using the patient’s response or score on a pain scale and include the pain scale utilized during the assessment (Ball, et al., 2015).
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT: 5’10”; WT: 248Ibs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no uticaria
Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
Objective data are the findings resulting from direct observation- what you see, hear, and touch. Relate physical findings to the processes of inspection, palpation, auscultation, and percussion (Ball, et al., 2015). Fever is a cardinal manifestation of disease. Generally, low grade fever occurs with viral causes of diarrhea such as the one listed in this scenario. Additional questions that could be asked would include: Have you traveled recently? Where? Have you taken any antibiotics recently? Which ones? Do you drink milk or eat milk products? Do you eat wheat products? Have you recently eaten raw or undercooked poultry, seafood, or beef? Location of pain can direct a provider in narrowing down diagnosis based on location. The pain from ulcerative colitis may occur over the entire abdomen or may be localized to the lower quadrants. Large intestine pain is felt in the lower abdominal quadrants, whereas small intestine pain is felt in the epigastric and umbilical areas (Dains, et al., 2016).
Left lower quadrant pain
Differential diagnosis may include: Viral Gastroenteritis, Shigella, which is an infection that presents with acute diarrhea that contains mucous and blood and typically last up to seven days, which is not present in the scenario, or food poisoning. Food poisoning can come from many organisms such as staphylococci or Bacillis aureus or Clostridium perfringens (Dains, et al., 2016). Typically, all forms of food poisoning present with diarrhea, abdominal cramping. With food poisoning a fever is uncommon and the diarrhea usually subsides within 18-26 hours, which in the scenario listed above, the patient had a low-grade fever and had been having frequent stools for three days.
Laboratory or diagnostic studies are not necessary if the patient appears to have a viral or toxigenic bacterial infection because the disease is usually mild. As advanced practitioners, we should reserve stool cultures for relatively ill patients with signs of invasive or persistent diarrhea (Dains, et al., 2016). The diagnosis of diarrhea predominant irritable bowel syndrome (IBS-D) is based on clinical presentation and several laboratory and diagnostic procedures to exclude other organic conditions. A blood test has been developed which tests for two biomarkers associated with IBS-D (Pimentel, et al., 2015).
Given the information listed in the SOAP note I would concur with the diagnosis of gastroenteritis. Acute diarrhea in adults is commonly viral in origin. Viral gastroenteritis presents with an explosive onset of diarrhea, vomiting, low-grade fever, anorexia, and myalgia. Symptoms typically last for one week or less. Norwalk virus is a major causative agent (Dains, et al., 2016). Typical presentation of viral acute gastroenteritis includes a short prodromal phase, with mild fever and vomiting, followed by one to four days of non-bloody, watery diarrhea (Sidoti, et al., 2015). The subjective and objective data listed in this scenario are consistent with the diagnosis of gastroenteritis due to the patient presents with a mild low-grade fever, symptoms only presenting for less than a week, and having intermittent nausea.
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.
Pimentel, M., Purdy, C., & Magar, R. (2015). Cost-Minimalization For A Novel Ibs Diagnosistc Blood Panel Versus Standard Eclusionary Diagnostic Testing For Diarrhea Predominant Irritable Bowel Syndrome: A United States Perspective. Value in Health: The Journal Of the Internatial Society For Pharmacoeconomics And Outcomes Research, 18(7), A350. https://doi-org.ezp.waldenulibrary.org/10.1016/j.jvai.2015.09.636
Sidoti, F., Ritta, M., Costa, C., & Cavallo, R. (2015). Diagnosis of viral gastroenteritis: limits and potential of currently available procedures. Journal of Infection in Developing Countries, 9(6), 551-561. http://doi-org-ezp.waldenulibrary.org/10.3855/jidc.7051.