Assignment: NURS 6512 Week 6 Assessing The Abdomen

SUBJECTIVE DATA

PATIENT INFORMATION

Name: L.Z

Age: 65 years

Gender at birth: Male

Gender of Identity: Male

Race: African American

Source of information: the patient

Chief Complaint: “My stomach has been hurting for two days.”

History Of Presenting Complaint: L.Z, a 65 years old African American 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 he was given proton pump inhibitors with no relief. Presently, the patient reports that the pain has been increasing in severity over the past few hours. It has no specific timing, no aggravating or relieving factors. He vomited after lunch, which led him to go to the emergency department at this time. The vomiting was non-projectile and not preceded by nausea. The vomitus was neither bloodstained nor bilious and only contained food contents. He has not experienced fever, diarrhea, or other symptoms associated with abdominal pain.

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Past Medical History: The patient has been hypertensive for ten years.

Past Surgical History: he denies a history of surgery.

Medications: Metoprolol 50 mg

Allergies: The patient has no known drug, environmental, food, chemical, or animal allergy.

Family History: the patient’s mother has hypertension and hyperlipidemia. His father suffers from gastroesophageal reflux disease. His brother also has hypertension. His sister is alive and well with no medical conditions. He denies a history of malignancies in the family.

Social History: The patient works in a restaurant as a store manager. He drinks alcohol. He has been smoking for twenty years but reports that he quit smoking two years ago. He was divorced five years ago. He has three children, two males and one female. He denies taking other recreational drugs apart from the ones mentioned above.

Analysis: the chief complaint given is complete. The history of presenting complaints has been expressed well. However, this subjective portion of the history is not complete. I would have wished to know more about the vomiting. When does it occur? What is the color? What are the contents? Is it projectile or not? Is it bilious or bloodstained? Is it preceded by nausea? Are there any relieving factors? I would have also wished to ask if the patient experienced any episodes of syncope or fainting. Additionally, the review of systems was not done comprehensively to determine if there are other associated symptoms or other symptoms that are related. A history of hypertension has been provided as well as that of hyperlipidemia. I would have wished to find out details of the same. For how long the patient has been suffering from the same? Are the conditions well-controlled or not? I would have also wished to know if the patient has ever been hospitalized. If so, then for what reason and for how long? There is also a need to ask for a history of a similar occurrence in the family and any history of cancer in the patient’s family. The patient’s immunization status is also missing from the data given and it is so essential. Additionally, I would have wished to get more information as to whether the patient went on a drinking spree or had binge drinking before the abdominal pain began. I would also like to know what kind of diet the patient takes and whether he exercises regularly.

OBJECTIVE DATA

Vital Signs: Temperature 98.2, Blood Pressure 91/60 mmHg, Respiratory Rate 16, Pulse Rate 76 bpm, Oxygen Saturation 98% on room air, Height 6’ 10”, Weight 262 lbs, BMI 29.5

Heart: precordium is normoactive, with no heaves or thrills. RRR, S1, and S2 heard, no murmurs.

Lungs: CTA, chest symmetrical, no chest wall deformities. No tenderness, the trachea is central, equal chest expansion, tactile fremitus. Percussion note is resonant in all the lung fields. On auscultation, there is equal and bilateral air entry in all the lung fields; vesicular breath sounds are heard, but no added sounds.

Skin: intact without lesions, no urticarial

Abdomen: abdomen is of normal fullness and moves with respiration. No caput medusa, no obvious masses or distension. It is tender in the epigastric area with guarding but without mass or rebound. Bowel sounds are present, twelve per minute.

Analysis: The objective part of this case study was done well. However, it was not complete. In the vital signs, the oxygen saturation, and the body mass index were not provided. The body mass index is very vital because the patient has hypercholesterolemia. The general appearance of the patient was also not noted. It is usually important to note the general appearance as it can give one an idea of the patient and also inform the management plan. Examination of the abdomen did not tell whether there was a pulsatile mass which is usually one sign of an abdominal aortic aneurysm. The examination of the cardiovascular system was thoroughly done. All the peripheral blood vessels were examined properly and carefully. The respiratory system was also examined well. However, the other systems were not examined. The patient should be examined as a whole. The head, eyes, ears, neck, nose, and throat were to be examined as well and the information recorded. The neurological system, the genitourinary system, and the musculoskeletal systems were to be examined thoroughly as well and the findings were noted. These findings would help in determining which diagnostic tests are to be done. Besides, they would also help in making decisions concerning the management of the patient.

Assessment: The assessment of the patient is supported by subjective and objective data. From the subjective data, the patient is an elderly male, who has hypercholesterolemia and hypertension. There is also history of smoking and alcohol consumption. The information provided in the subjective portion is a risk factor for the development of abdominal aortic aneurysm. Proton pump inhibitors do not relieve abdominal pain. This automatically throws out peptic ulcer disease as a potential diagnosis, unless it is perforated. Additionally, there is no history of binge drinking before the pain began. This possibly rules out the possibility of acute pancreatitis though it is still a differential considering that the patient smokes and drinks as well. The objective portion of the note focused so much on the cardiovascular, abdominal, and lung examination. The findings recorded also gravitated towards the same potential diagnosis. Besides, the tests that have been ordered are very specific in diagnosing abdominal aortic aneurysms.

Diagnostic Tests

CT scan of the abdomen. This will help tell us where the pathology is in the abdomen, the size, and the organs involved.
Abdominal ultrasound. It is a cheap imaging modality that can show us what pathology is in the abdomen, whether there is an enlarged organ or a swelling.
This will tell which vessel is affected and at what point.
This is used in case the patient is allergic to contrast used in CTA.
Helicobacter pylori test is also required to find out if the patient has peptic ulcer disease
An erect abdominal radiograph is to check for any perforation of the viscera.
Serum lipase levels. This will help in ruling in or out the possibility of pancreatitis.

Diagnosis

Abdominal Aortic Aneurism

I would accept this diagnosis. This is because, from the history, the patient is above the age of 60, is hypertensive, drinks alcohol, and has been a smoker for a long time. Additionally, he has a family history of hyperlipidemia and he is male. According to Shaw et al. (2023), all these factors are a risk for the development of abdominal aortic aneurysm. Bailey et al. (2023) state that smoking is the strongest risk factor for the development of this condition. The history is strongly suggestive of the diagnosis. In addition, the provision of the proton pump inhibitors did not alleviate the patient’s pain, meaning that the pain is not caused by excess acid in the stomach. All that is suggestive of abdominal aortic aneurysm. When the aneurysm enlarges, it can cause abdominal pain, as in the case of this patient.

Differential Diagnosis

Perforated Ulcer: Peptic ulcer is a condition that is caused by Helicobacter pylori or the use of nonsteroidal anti-inflammatory drugs. It normally affects the stomach and the duodenum. It is a chronic condition that is initially asymptomatic but can present with abdominal pain, usually after taking meals, and heartburn. Later stages of the disease can present with gastrointestinal bleeding, perforation, and obstruction. When the ulcer is perforated, the patient will present with sudden epigastric pain and a feeling of lightheadedness that results from syncope. Because of the perforation, there is a loss of blood and a fall in blood pressure that causes syncope. The patient presents with a sudden onset epigastric pain, making this a differential diagnosis.

Pancreatitis: Acute pancreatitis refers to an injury to the pancreas. According to Mohy-ud-din and Morrissey (2022), gallstones and alcohol use are the two most common causes of pancreatitis. A patient with pancreatitis will present with sharp epigastric pain that radiates to the back, nausea, and vomiting. The patient has the above symptoms and a family history of hyperlipidemia which makes this diagnosis possible.

Acute Gastritis: This condition refers to inflammation of the gastric mucosa. It can be caused by pathogens like Helicobacter pylori, autoimmune processes, or even due to reflux of acidic contents. There are no specific symptoms for this condition, but patients will complain of epigastric pain, vomiting, and nausea (Azer & Akhondi, 2023).

References

Azer, S. A., & Akhondi, H. (2023). Gastritis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544250/

Bailey, I. B., Shaydakov, M. E., & Shaw, P. M. (2023). Abdominal Aorta Aneurysm Repair. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430752/

Mohy-ud-din, N., & Morrissey, S. (2022). Pancreatitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538337/

Shaw, P. M., Loree, J., & Gibbons, R. C. (2023). Abdominal Aortic Aneurysm. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470237/

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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 exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible.

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.

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.

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:

Abdominal Aortic Aneurysm (AAA)

Perforated Ulcer

Pancreatitis