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
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
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.
Welcome to Week 6. You will complete an analysis of the SOAP note provided. This can be written in narrative or SOAP note format. Analyze the subjective and objective section of the note and list any additional information that should be included. Review syllabus for additional information to include.
Assignment 1: Lab Assignment: Assessing the Abdomen
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A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CT scan. The CT 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 Lab Assignment, you will analyze an Episodic 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.
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.
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 three different references from current evidence-based literature.
With regard to the SOAP note case study provided, address the following:
Analyze the subjective portion of the note. List additional information that should be included in the documentation.–
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 17: Abdomen
This review discusses examination of the abdomen.
• Before the exam, gather the necessary equipment: stethoscope, centimeter ruler, non-stretch tape measure, and marking pen.
To inspect the abdomen, perform the following.
• Using tangential lighting, inspect the abdomen for four surface characteristics.
o First, observe the skin color. It may vary greatly but should have no jaundice, cyanosis, redness, bruises, or discoloration.
o Second, check for nodules and other lesions, which should not be present.
o Third, note any scars and draw their location, configuration, and relative size on an illustration of the abdomen.
o Fourth, assess the venous return. Above the umbilicus, venous return should be toward the head. Below the umbilicus, it should be toward the feet.
• Next, inspect the abdominal contour and symmetry.
o The contour is the abdominal profile from the rib margin to the pubis. It normally may be flat, rounded, or scaphoid. The umbilicus should be centrally located and may be inverted or may protrude slightly.
o Contralateral areas of the abdomen should be symmetrical in appearance and contour and should have no distention or bulges.
o To elicit hidden masses or bulges, have the patient take a deep breath and hold it. The abdomen should remain smooth and symmetrical. Next, have the supine patient raise their head from the table as you inspect the abdomen. Note any masses, hernia, or muscle separation.
• With the patient’s head at rest, observe for three types of abdominal movement.
o First, inspect for smooth, even movement with respiration.
o Second, assess for surface motion from peristalsis. In a thin patient, it normally may be visible. Otherwise, it may signal an intestinal obstruction.
o Third, note any aortic pulsation in the upper midline. Although pulsations may be visible in a thin patient, marked pulsations suggest a disorder.
To auscultate the abdomen, perform the following.
• Remember to auscultate before you percuss or palpate because these techniques can alter bowel sounds. Using the diaphragm of a warmed stethoscope, listen for bowel sounds and note their frequency and character.
o Expect to hear clicks and gurgles at a rate of 5 to 35 per minute.
o Note unexpected findings, such as increased or decreased bowel sounds or high-pitched tinkling sounds.
• Auscultate for three additional sounds.
o First, use the stethoscope diaphragm to detect high-pitched friction rubs over the liver and spleen.
o Second, use the stethoscope bell to check for bruits over the aortic, renal, iliac, and femoral arteries.
o Third, use the stethoscope bell to assess for a soft, continuous, low-pitched venous hum in the epigastric area and around the umbilicus.
To percuss the abdomen, perform the following.
• Systematically percuss for tone in all abdominal quadrants.
o Tympany is heard over the stomach and intestines.
o Dullness is heard over organs and solid masses.
• Percuss to estimate the liver span, using three steps.
o First, determine the lower border of the liver by percussing up from an area of tympany along the right midclavicular line. Mark the point where tympany changes to dullness, which usually occurs at or slightly below the costal margin.
o Second, determine the upper border of the liver by percussing down from an area of resonance along the right midclavicular line. Mark the point where resonance changes to dullness, which usually is in the fifth intercostal space.
o Third, measure the distance between the marks. The vertical liver span usually ranges from 6 to 12 cm.
• To assess liver descent, ask the patient to take a deep breath and hold it while you percuss the lower border again. With this maneuver, the area of dullness at the lower border should shift down 2 to 3 cm.
• Percuss the spleen just posterior to the midaxillary line on the left side, beginning in areas of lung resonance and moving in several directions. You normally may hear a small area of splenic dullness from the sixth to ninth rib. Percuss the lowest intercostal space in the left anterior axillary line before and after the patient takes a deep breath. Tympany should remain in this area.
• Percuss for the gastric air bubble in the left lower anterior rib cage and left epigastric region. Gastric bubble tympany is lower in pitch than intestinal tympany.
• With the patient seated, percuss the kidneys, following two steps.
o First, place the palm of your hand over the right costovertebral angle and strike it with the side of the fist of your other hand.
o Second, repeat this action on the left costovertebral angle. In both locations, the patient should feel a thud but no pain.
To palpate the abdomen, perform the following.
• Using light palpation, systematically assess all quadrants. But first, try to relax the abdominal muscles. For example, place a small pillow under the patient’s head and slightly flexed knees, warm your hands, take a slow and gentle approach, and save any tender areas for last. For light palpation, press in no more than 1 cm with the palmar surface of your fingers.
o Expect the abdomen to feel smooth and soft.
o Note any resistance or tenderness. And watch for guarding, which should alert you to proceed with caution.
• Using moderate palpation, systematically assess all quadrants in two ways.
o First, palpate with the palmar surface of your fingers. This may elicit tenderness that was not produced by light palpation.
o Second, palpate with the side of your hand throughout the respiratory cycle. As the patient inhales, you may feel the liver and spleen bump gently against your hand.
• Using deep palpation, systematically assess all quadrants with the palmar surface of your fingers. If a patient’s obesity or muscular resistance makes deep palpation difficult, try bimanual palpation with one hand on top of the other. With either technique, feel for the rectus abdominis muscles, aorta, and portions of the colon. Note any tenderness.
• If you detect a mass, evaluate its location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration. To see if the mass is superficial or intraabdominal, palpate as the patient lifts his or her head off the table. A superficial mass will remain palpable; an intraabdominal mass will not.
• Palpate the umbilical ring and periumbilical area. The umbilical ring should feel round and regular. The area should have no bulges, nodules, or granulation.
• Palpate for specific abdominal structures.
o For the liver, press in and feel for its edge at the right costal margin as the patient takes a deep breath. If palpable, the liver should feel firm, smooth, even, and nontender.
o For the gallbladder, palpate below the liver margin at the lateral border of the rectus abdominus muscle. A healthy gallbladder is not palpable.
o For the spleen, press in over the left costal margin as the patient takes a deep breath. The spleen is not usually palpable.
o For the kidneys, assess the right and left organs separately, placing one hand on the flank and the other hand on the costal margin. As the patient inhales deeply, lift the flank and palpate deeply. The right kidney is more commonly palpable than the left kidney.
o For the aorta, palpate deeply for the aortic pulsation slightly left of the midline. If the pulsation is prominent, try to determine its direction.
o For the bladder, palpate above the symphysis pubis. If the bladder is distended with urine, it feels like a smooth, round, tense mass.
To assess the abdomen further, perform the following.
• If you suspect ascites, percuss the supine patient’s abdomen for dullness in the dependent parts and tympany in the upper parts. Also assess for shifting dullness or fluid wave.
• If the patient reports abdominal pain, assess it thoroughly, especially its quality and location. When examining the abdomen, be sure to watch the patient’s face for clues to pain. If needed, assess for rebound tenderness and perform the iliopsoas muscle and obturator muscle tests.
• If you suspect a freely movable abdominal mass, perform ballottement.
Chapter 6, “Vital Signs and Pain Assessment”
This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
Chapter 18, “Abdomen”
In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.
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.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 3, “Abdominal Pain”
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”
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”
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”
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.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
These sections below explain the procedural knowledge needed to perform gastrointestinal procedures.
Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)
Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520)
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
NURS 6512 Week 6 Assignment NURS 6512 Week 6 Assignment
Name of the Student Institutional Affiliation of the Student Course
Name of the professor and the date
NURS 6512 Week 6 Assignment NURS 6512 Week 6 Assignment
Subjective Information that is not required
It is required to obtain further subjective information because the patient was unable to adequately express his or her pain. The patient did not specify the location of the abdominal pain when she reported it. The discomfort was not described by the patient, despite his attempts to do so. He described the agony as throbbing, acute, shooting, and cramping. The patient did not provide a detailed account of what occurred when the pain began. He didn’t go into detail about the types of foods that cause the discomfort. He did not elaborate on how long the pain lasts or on any aggravating circumstances, such as defecating or belching, that may contribute to it. Patients are required to provide a thorough review of their systems in order to ensure a thorough assessment.
System Evaluation Through the Eyes of the Beholder
General: There was no weight loss or gain, nor was there any fever or weariness.
HEENT: There is no vision loss, yellowing of the sclera, or blurring of vision. There are no hearing issues. There will be no running nose. There was no tonsillitis.
Skin: There are no sores, itching, or rashes on the skin.
Edema, chest pressure, discomfort, or chest pain are not present in the cardiovascular system.
Respiratory: There is no shortness of breath, coughing, or production of sputum in the system.
Abdominal discomfort, nausea, and diarrhea are all symptoms of gastrointestinal distress. There will be no vomiting.
Genitourinary: There are no urinary issues.
Neurological: There were no headaches, seizures, or changes in bladder control observed.
Musculoskeletal: There is no discomfort or stiffness in the muscles.
Hematologic findings: There is no anemia or bruising.
No swollen lymph nodes or splenectomy were performed in the lymphatic system.
Psychiatric: There are no signs of depression or anxiety.
Endocrinologic: There have been no reports of excessive sweating, polyuria, or dysuria.
None of the following allergies exist: eczema, rhinitis, or asthma.
Objective Information that is not already known
An examination of the groin should be performed as part of a comprehensive evaluation of the patient. The goal is to rule out the possibility of an incarcerated hernia or testicular torsion as the source of the pain. Tenderness of the flanks is determined by percussing the meat on the bone (Jackson & Cruz, 2018). The presence of kidney stones, for example, can be indicated by flank pain. The vaginal and prostrate areas should be examined by a healthcare provider to rule out the presence of sexually transmitted illnesses. A nurse should examine fecal occult or frank blood for signs of infection. For example, the presence of blood may signal the existence of cancer or the presence of an emergency situation (Jackson & Cruz, 2018). In some cases, abdominal discomfort might be referred to other organs or sections of the body, necessitating a physical examination of the heart, lungs, head, and neck.
Is the current diagnosis a satisfactory one?
The current diagnosis does not meet the criteria for additional tests and investigations that are required. However, in order to rule out other probable illnesses, the advanced nurse practitioner should perform additional tests to confirm the diagnosis of gastroenteritis (Dains et al., 2018). Patients suffering from gastroenteritis, for example, may have diarrhea, fever, vomiting, hyperactive bowel sounds, and nausea, among other symptoms. A vomiting episode has not been noted by the patient in the case study. Gastroenteritis is a condition that can resolve on its own.
Tests for Diagnosis
Prior to performing diagnostic tests, it is vital to obtain a comprehensive medical history from the patient. There is no requirement for laboratory tests. Patients with a prolonged fever or blood in their stool or urine, on the other hand, may require additional testing (Dains et al., 2018). X-rays and CT scans are examples of tests that may be used to aid in the diagnosis of this condition.
Differential Diagnosis is a medical term that refers to the process of determining whether or not anything is wrong.
Other disorders such as irritable bowel syndrome, intestinal blockage, and ureterolithiasis could be indicated by the patient’s ambiguous symptoms, which could be indicative of other conditions as well.
Chronic constipation and abdominal cramps are symptoms of irritable bowel syndrome, which is a prevalent illness characterized by diarrhea, bloating, diarrhea, constipation, and abdominal cramping. For the patient, a gastrointestinal examination as well as a blood test are required (Brady & Pade, 2018). If the condition is not present, the blood test results in a negative result. An advanced nurse practitioner should take into account the patient’s history of colorectal cancer as well as his or her age. Other concerns include whether or not the stool contains blood and whether or not the patient shows improvement between 6 and 8 weeks (Brady & Pade, 2018). Proctosigmoidoscopy will be performed as a result of the considerations.
The syndrome happens in patients who have had recent gastrointestinal surgery, the elderly, and infants, among other groups of people. In addition to adhesions that form after surgery and colon cancer as well as hernias and diverticulitis, there are other blockage causes (Brady & Pade, 2018). Patients present with crampy pain that appears out of nowhere. Patients complain of nausea and vomiting. The presence of obstruction causes diarrhea, whereas partial obstruction causes diarrhea. When there is an obstruction, there are hyperactive bowel noises present. When there is an obstruction, there is abdominal distention present (Reddy & Cappell, 2017). In order to diagnose the condition, an advanced nurse practitioner should perform X-rays, an MRI, or a CT scan.
Ureterolithiasis is a disorder that develops when kidney stones lodge in the ureters of the kidneys. Patients with the illness complain of excruciating colicky discomfort that might progress to chronic agony over a period of time. Symptoms include lower abdominal and groin pain in some patients (Brady & Pade, 2018). Vomiting, chills, and abdominal distention are among the other signs and symptoms. Patients may also have hematuria and increased frequency of urination. The diagnosis comprises a urine examination to detect the pH of the urine as well as an analysis of the stone composition (Brady & Pade, 2018). A non-contrast-enhanced helical computed tomography CT scan can also be used to make a diagnosis.
Brady, K., and Pade, K. H. (in press) (2018). An evidence-based approach to the management of acute gastroenteritis in pediatric patients [digest]. Acute Care in Pediatric Emergency Medicine, vol. 15, no. 2 (supplementary points and pearls), pp. 1–2.
In J. E. Dains and L. C. Baumann’s article, P. Scheibel describes how they came to be (2018). In this e-book, you will learn about advanced health assessment and clinical diagnosis in primary care. Elsevier Health Sciences is a publisher of health-related information.
Jackson, P., and Cruz, M. V. (in press) (2018). Evaluation and treatment of intestinal blockage. The American Family Physician, vol. 98, no. 6, pp. 362-367.
S. R. R. Reddy and M. S. Cappell are two of the most well-known scientists in the world (2017). A systematic study of the clinical presentation, diagnosis, and treatment of small bowel obstruction was carried out by the researchers. Journal of Gastroenterology and Hepatology, 19(6), 28.