NURS 6512 Week 6: ASSIGNMENT 1: LAB ASSIGNMENT, ASSESSING THE ABDOMEN
Week 6 – The Episodic note case study: Abdominal Assessment
- CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
- HPI: JR, 47 y/o WM, complains of having generalized abdominal pain that started three days ago. He may not have 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 afterward.
- PMH: HTN, Diabetes, hx of GI bleeding four 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, three children (1 girl, two 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 from the case study that you have been provided for this week’s Assignment.
- Concerning 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.
- Does the 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 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.
This should be written as a narrative/paragraph only!
DO NOT rewrite a SOAP note. Tell me what is wrong with the Episodic SOAP Note by responding to the statements/questions above.
Read the SOAP note for Abdominal Assessment, do this in paragraph form.
This paper discusses the case study of JR, a 47-year-old who presented with generalized abdominal pain, diarrhea, and nausea. He has a history of hypertension, diabetes, and was managed for UGIB (upper GI bleeding) four years ago. He was on Lisinopril 10 mg, Amlodipine 5mg, Metformin 1000mg, and Lantus 10 units. He takes ethanol occasionally. Has a family history of hypertension, diabetes type two, GERD, and hyperlipidemia. He is married and has three children.
The patient presented with generalized abdominal pain. Other than the severity of the pain on a scale of 0-10, describe the character of the pain, was it sharp, dull, or of burning sensation. Ask if the pain is radiating or not, is the pain increasing or decreasing in severity, where is the specific origin of the pain. Ask about the onset of the pain, gradual or acute onset, and the specific time the pain occurs. What is the main cause of the pain and what relieves the pain? Ask if the pain has other associating factors like reflux. According to, Alameri (2020), expounding more about the pain; site, onset, character, aggravating factors, relieving factors, and timing, helps to narrow down to the most probable diagnoses.
The pain is associated with diarrhea, it is important to know how many episodes in a day, the number of days he experiences diarrhea. What was the content of diarrhea, is it food or water, the color of the stool, is it yellow-white or green, was the smell foul-smelling or non-foul smelling. What are the aggravating factors, relieving factors, and associating symptoms? The clinician should also determine if there was an association between diarrhea and painful urination or urine discoloration. According to Padhy et al (2017), patients with pancreatic cancer often experience stool lightening and dark urine. Expound on other symptoms of the gastrointestinal system like nausea, vomiting, heartburn, reflux, weight loss, and loss of appetite. Having a previous medical history of UGIB four years ago, ask if he has experienced, hematemesis, and Malena stool. Therefore, information on the absence or presence of blood in vomitus or stool should be included noting the color and smell. Ask if he complies with medication since he is diabetic and hypertensive
Vital Signs include, Blood Pressure 160/86mmHg, RR-16, Temperature99.8, PR 68, Height 5’10, and Weight-248lbs (BMI-33.8 obese). Upon general examination, report if the patient is sick looking or is in fair general condition, note if the patient is in severe pain, nutrition status, and the posture. Look for pallor, jaundice, cyanosis, dehydration, and lymphadenopathy. Often, patients with pancreatic cancer are pale, lethargic, and emaciated (Padhy et al (2017). The abdominal examination includes palpation, percussion, inspection, and auscultation of the abdomen. On inspection, report about abdominal distension and movement with respiration. Note any stretch marks, scars, and veins.
Per abdomen, palpation is categorized into two, light palpation and deep palpation. Palpate lightly for any obvious mass. Deep palpation checks for tenderness and organ enlargement. Palpable masses suggest tumors, bowel that is obstructed, or aneurysm
On percussion, note different sounds at different abdominal quadrants. Percuss for dullness, shifting dullness, and tympanic note. Auscultate the abdomen for bowel sounds and bruits. In this case, the abdomen is soft with hyperactive bowel sounds with tenderness at the left lower quadrant (pos pain). Pain at the left lower quadrant is suggestive of diverticulitis and gastroenteritis (De Virgilio et al 2020). Examinations of other systems like the cardiovascular system, the heart rate is normal, regular rhythm heart sounds are present. The chest wall is symmetrical. Skin color is normal, with no urticarial.
The patient presents with lower quadrant pain and gastroenteritis. The patient presents with generalized abdominal pain, nausea, and diarrhea with no history of vomiting. Patients with pancreatic cancer may present with abdominal pain and diarrhea. The pancreas is not able to produce pancreatic enzymes that help during food digestion hence indigestion that leads to diarrhea (Moffat, Epstein & O’Reilly, 2019). Tenderness at the left lower quadrant of the abdomen is associated with pain that could affect other organs like the ileum, rectum, ureter, and other parts of the colon. Since the patient reported of generalized pain and diarrhea, the pain at the left lower quadrant was due to gastroenteritis.
Investigations are important before making a diagnosis, some of the important investigations are; a full hemogram, tumor markers test, and a liver function test. A hemogram is necessary to rule out any infection, anemia of chronic illness, and thrombocytosis that is specific in pancreatic cancer. Random blood sugar would rule out hyperglycemia, which is present in pancreatic cancer. According to, Padhy et al (2017), a liver function test would indicate elevated levels of liver enzymes, which is a feature of obstructive jaundice. It is advisable to do a tumor marker test to rule out pancreatic cancer. The recommended imaging is an abdominal pelvic CT scan.
Potential Differential Diagnosis
The diagnosis for this patient is pancreatic cancer. Clinically it presents with generalized abdominal pain that is of gradual onset, jaundice, diarrhea, reduced appetite, loss of weight, and vomiting (Moffat, Epstein & O’Reilly, 2019). However, patients may have poor glycemic control due to inadequate insulin production. Similarly, the patient in this case presents with abdominal pain that was gradual, diarrhea, and minimal nausea. On examination, there was tenderness at the left lower quadrant. Thus, the author accepts the current diagnosis.
Possible Differential Diagnoses
Differential diagnoses are pancreatic lymphoma, gastric lymphoma, abdominal aortic aneurysm, and intestinal ischemia.
Alameri, A., Al Hillan, A., Museedi, A. S., Oglah, A., Alklhero, M., & Velásquez, S. T. (2020). Gastritis in the Setting of Chronic Abdominal Pain. European Journal of Case Reports in Internal Medicine, 7(9).
De Virgilio, C., Arnell, T. D., Frank, P. N., & Petrie, B. A. (2020). Left Lower Quadrant Pain In Surgery (pp. 297-302). Springer, Cham.
Padhy, B., Murmu, D., Samal, D., & Jha, S. (2017). Clinical study of surgical jaundice: an institutional experience. International Surgery Journal, 5(1), 138-142.
Moffat, G. T., Epstein, A. S., & O’Reilly, E. M. (2019). Pancreatic cancer—A disease in need: Optimizing and integrating supportive care. Cancer, 125(22), 3927-3935.
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