Walden University-NURS 6512, week 6, assignment 1 (abdomen)
Please use the following resources for citations and references when possible:
*Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
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 Download 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”Download 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”Download 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”Download 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 115, “X-Ray Interpretation of Abdomen” Download “X-Ray Interpretation of Abdomen”(pp. 514–520).
Assignment 1
You will analyze an Episodic note case study (listed below) that describes abnormal findings in patients seen in a clinical setting. WRITE THIS UP AS A NARRATIVE so that you are able to correctly explain the analysis. 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.
!!!Please DO NOT write this up in a soap note format!!!
You are NOT completing a soap note but analyzing all the information provided and discussing in your narrative what information is missing. You need to take all of the information presented into consideration to determine what is missing. Analyze all information. Please use your textbook guide to clinical documentation to help with this assignment. It will be a great resource to use for this assignment as well as the required resources for this week.
ABDOMINAL ASSESSMENT
Abdominal Assessment
Subjective:
CC: "My stomach has been hurting for the past two days."
HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain.
PMH: HTN
Medications: Metoprolol 50mg
Allergies: NKDA
FH: HTN, Gerd, Hyperlipidemia
Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female
Objective:
VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: The abdomen is tender in the epigastric area with guarding but without mass or rebound.
Diagnostics: US and CTA
Assessment:
Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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.
The Assignment:
(In the past some students have listed each question that needs to be answered and then wrote there narrative under each question). This is easier for some students.
*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.
Thank you, Peter!
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