Assignment 1: Lab Assignment: Assessing the Abdomen

A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA; however, as a precaution, the doctor ordered a CTA scan.

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 assessments 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.

• About      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 assessment 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.

Case study

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: abdomen is tender in the epigastric area with      guarding but without mass or rebound.
• Diagnostics: US and CTA

Assessment:

1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis

PLAN: 

The Assignment

1. Analyze      the subjective portion of the note. List additional information that      should be included in the documentation.
2. Analyze      the objective portion of the note. List additional information that should      be included in the documentation.
3. Is      the assessment supported by the subjective and objective information? Why      or why not?
4. What      diagnostic tests would be appropriate for this case, and how would the      results be used to make a diagnosis?
5. 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.