Episotic/focusedaAssessment of the Abdomen

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

Grading 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.
The
response clearly, accurately, and thoroughly analyzes the subjective portion of
the SOAP note and lists detailed additional information to be included in the
documentation.

Analyze
the objective portion of the note. List additional information that should be
included in the documentation.
The
response clearly, accurately, and thoroughly analyzes the objective portion of
the SOAP note and lists detailed additional information to be included in the
documentation.

Is
the assessment supported by the subjective and objective information? Why or
why not?
The
response clearly and accurately identifies whether or not the assessment is
supported by the subjective and/or objective information, with a thorough and
detailed explanation.
What
diagnostic tests would be appropriate for this case, and how would the results
be used to make a diagnosis?
The
response thoroughly and accurately describes appropriate diagnostic tests for
the case and explains clearly, thoroughly, and accurately how the test results
would be used to make a diagnosis.
·
Would you reject or 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.
The
response states clearly whether to accept or reject the current diagnosis, with
a thorough, accurate, and detailed explanation of sound reasoning. The response
clearly, thoroughly, and accurately identifies three conditions as a
differential diagnosis, with reasoning that is explained clearly, accurately,
and thoroughly 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 continuity of ideas.
Sentences are carefully focused–neither long and rambling nor short and
lacking substance. A clear and comprehensive purpose statement and introduction
are provided that delineate all required criteria.
Paragraphs
and sentences follow writing standards for flow, continuity, and clarity. A
clear and comprehensive purpose statement, introduction, and conclusion are
provided that delineate all required criteria.

Written
Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
Uses
correct grammar, spelling, and punctuation with no errors.
Written
Expression and Formatting – The paper follows correct APA format for title
page, headings, font, spacing, margins, indentations, page numbers,
running heads, parenthetical/in-text citations, and reference list.
Uses correct
APA format with no errors.

Case
Study

In this Assessment 1
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 exams and diagnostic tests should be conducted. You will also formulate
a differential diagnosis with several possible
conditions. Just add in what you want to
this case to make it unique to you. Do not use NA or normal.

ABDOMINAL ASSESSMENT

Subjective:

• CC: “My stomach hurts, I have diarrhea and
nothing seems to help.”

• 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)

Objective:

• 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: ?

Assessment:

• Left lower quadrant pain

• Gastroenteritis

PLAN:
This section is not required for the assignments in this course (NURS 6512) but

will be required for future courses.

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