Assignment: Assessing The Abdomen

Assignment: Assessing The Abdomen

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

A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, the doctor ordered a CT scan as a precaution. The CT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.

Because of the 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 diagnose conditions in the abdomen better.

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 and which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

To Prepare

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 their insights 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.

The Assignment

• 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.
• Does subjective and objective information support the assessment? 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 conditions that may be considered a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

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.

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment: Assessing The Abdomen

Chapter 18, “Abdomen”

Assignment: Assessing The 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.

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

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. It is reprinted by permission of Mosby via the Copyright Clearance Center.

Rubric:

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.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Does subjective and objective information support the assessment? 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 or accept the current diagnosis? Why or why not?
• Identify three conditions that may be considered a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Written Expression and Formatting – Paragraph Development and Organization:

• Paragraphs make clear points that support well-developed ideas flow logically and demonstrate the continuity of ideas.
• Sentences are carefully focused–neither long, rambling, short, nor lacking substance.
• A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

Written Expression and Formatting – English writing standards:

• Correct grammar, mechanics, and proper punctuation

Written Expression and Formatting – The paper follows the correct APA format for thetitle page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

Attachment

• Week6AbdominalAssessment_1_.pdf
• Assignment: Assessing The Abdomen

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort, and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized.

Read over your paper – in silence and then aloud – before handing it in, and make corrections as necessary. Often, having a friend proofread your paper for obvious errors is advantageous. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12-point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. Letting your essay run over the recommended number of pages is better than compressing it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted and double-spaced with a one-inch margin on each page’s top, bottom, and sides. When submitting a hard copy, use white paper and print it out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

• Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
• Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
• One or two-sentence responses, simple statements of agreement or “good post,” and off-topic responses will not count as substantive. Substantive responses should be at least 150 words.
• I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

• Your initial responses to the mandatory DQ are graded separately and do not count toward participation.
• In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days for three replies.
• Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
• Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything due during the week.

APA Format and Writing Quality

• Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud, for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
• Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
• I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

• I discourage the overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
• As Master’s level students, you must be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding or critical analysis of the content.
• It is best to paraphrase content and cite your source.

 LopesWrite Policy

• For assignments that need to be submitted to LopesWrite, please be sure you have received your report, and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
• Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
• Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper more of someone else’s thoughts than yours?
• Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud, for tips on improving your paper and SI score.

Late Policy

• The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies.
• Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
• If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
• I do not accept assignments that are two or more weeks late unless we have worked out an extension.
• Per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask questions or send messages. This will be checked at least once every 24 hours.