Lab Assignment: Assessing the Abdomen
Lab Assignment: Assessing the Abdomen
ABDOMINAL ASSESSMENT
Subjective:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.â€
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)
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Objective:
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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
Assessment:
Left lower quadrant pain
Gastroenteritis
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.
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Abdominal Assessment
Abdominal problems have adverse effects on the health and wellbeing of the patients. Nurses are expected to utilize their knowledge and skills in comprehensive history taking and patient assessment to develop accurate diagnoses and treatment plans for their patients. Therefore, this paper is an examination of J.R’s case study. J.R is a 47-year-old client that has come to the hospital with generalized abdominal pain for the last three days and nausea. The purpose of this paper is to examine the additional subjective and objective information to be obtained from the client, whether the case study has subjective and objective data, diagnostic investigations, and decision related to the developed diagnosis.
Analysis of Subjective Portion
Subjective data relates to that obtained from the patient. It focuses on the experiences of the patient with the health problem. Additional subjective information should be obtained from the patient to come up with an accurate diagnosis and treatment plan. One of the subjective data that should be obtained from the client is quantification of the abdominal pain. Information about the pain rating, severity, character, and relieving, precipitating, and aggravating factors should be obtained. The other aspect of the pain should focus on whether the pain is generalized, radiating to other body parts, or increasing or decreasing in intensity. The pain should also be described in terms of whether it is sudden or gradual.
Moreover, the nature of diarrhea that the client reports should also be quantified. A focus should be placed on aspects such as the frequency of the diarrhea in a given period to determine if they client is dehydrated or not. The additional information about diarrhea include color of stool, relieving, aggravating, and precipitating factors. The provider should also obtain information about the dietary history of the client. Food poisoning could be a factor to consider in this client’s case. As a result, information about recent dietary habits and perceived hygiene of the foods should be obtained to determine the cause of the problem. The hygiene status and source of water that the client drinks should be obtained to ascertain whether the problem is a water-borne disease. Since the client has history of gastrointestinal bleeding, it would be necessary to ask about recent changes in color, smell, and texture of the stool prior to the current problems (Jarvis & Eckhardt, 2019). Such information will aid in ruling out causes such as ulcers of the gastrointestinal system.
Analysis of Objective Position
Healthcare providers obtain objective data using methods such as observation, palpation, percussion, and auscultation. The data is important in confirming or validating the subjective data given by the patient. Additional objective data should be obtained from the client. They include the general appearance of the client during the first encounter with the healthcare provider. The healthcare provider should provide a description of the grooming, energy levels, body weight, and if the patient is dehydrated or not. The provider should have also assessed the patient for hydration status and jaundice by checking on skin turgor and sclera for jaundice. The patient should have also provided comprehensive abdominal assessment to determine whether there is distention, bowel movements, organomegally, distention of veins, and scars. The provider should have also palpated the abdomen for tenderness, rigidity, or any rebound tenderness. The information could have helped rule out causes such as bowel obstruction and organomegally (Jarvis, 2019). The objective data could have facilitated the development of an accurate diagnosis for the client.
Analysis of the Assessment
Objective and subjective data support the assessment of JR. Examples of subjective data that supports the assessment include information about diarrhea, nausea, stomach pains, past medical, medication, allergies, family, and social histories. Examples of objective data include the vitals and heart, lungs, skin, and abdominal findings.
Diagnostic Tests
Stool test is the most appropriate diagnostic investigation for JR. Stool analysis should be performed to determine if the client has an infection or the cause could be due to gastrointestinal bleeding. Blood tests such as complete blood count are also recommended to determine if the client has low hemoglobin level due to bleeding or elevated white blood cell count to indicate infection. Since the client has a history of gastrointestinal bleeding, it would be appropriate to perform abdominal ultrasound to determine the actual cause of the problem (Jarvis & Eckhardt, 2019).
Rejecting/Accepting the Diagnosis
I would accept the current diagnosis. Patients with gastroenteritis experience symptoms similar to those of JR. The symptoms include abdominal cramps, vomiting, nausea, and diarrhea. The infection is short-term, implying symptom resolution over time. JR reports that the pain severity has declined, implying a potential symptom resolution in gastroenteritis. He also complains of diarrhea, abdominal pain, and nausea, hence, the decision to accept the diagnosis (Bányai et al., 2018). The differential diagnoses to be considered include abdominal obstruction, colon cancer, and inflammatory bowel disease. The above differentials have patients experiencing either nausea, vomiting, diarrhea, or abdominal pains. However, it may not be abdominal obstruction due to the presence of diarrhea and absence of abdominal distention. Diagnostic investigations such as abdominal ultrasound are needed to rule out colon cancer. The patient does not have any predisposition to environmental triggers, hence, ruling out inflammatory bowel disease (Guan, 2019).
Conclusion
Subjective and objective data guide the diagnoses developed for health problems affecting patients. JR is likely to be suffering from gastroenteritis. Additional subjective and objective data is however needed to develop an accurate diagnosis. Diagnostic investigations should be used to develop accurate diagnosis for the patient.
References
Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/S0140-6736(18)31128-0
Guan, Q. (2019). A Comprehensive Review and Update on the Pathogenesis of Inflammatory Bowel Disease. Journal of Immunology Research, 2019, e7247238. https://doi.org/10.1155/2019/7247238
Jarvis, C. (2019). Physical Examination & Health Assessment Access Code. Elsevier Health Sciences.
Jarvis, C., & Eckhardt, A. (2019). Physical Examination and Health Assessment. Elsevier.
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