Abdominal assessment case study Example
Assesment 1: Assessing the Abdomen
A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT 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 assignment, you will analyze a SOAP 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.
Abdominal Assessment
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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, hyperctive bowel sounds, pos pain in the LLQ
• Diagnostics: None
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.
To prepare:
With regard to the SOAP 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.
To complete:
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 3 different references from current evidence based literature.
By Day 7
Additional Information that should be Included in the Documentation of Subjective Data
Subjective data is the information that is given to a healthcare provider from the point of view of a patient. Therefore, it includes the concerns, feelings, and perceptions that are obtained through interviews. In the scenario given, the chief complaint of the patient was that of generalized abdominal pain. Apart from asking about the intensity of the pain on a scale of 0-10, it is important to include information on the quality of the pain, whether or not it is migratory or localized, increase or decrease in severity, where it originates from and radiates to. Besides, it should be included whether the pain was of sudden or gradual onset. The patient should also be asked to explain what she was doing when the pain started. The importance of determining any aggravating or relieving factors for the pain cannot be underestimated. As supported by Oberstein & Olive (2013), this information is essential in narrowing down to some of the most probable diagnoses.
Although the patient reported about diarrhea, additional information on bowel and urinary habits should be included. This includes the duration and an approximate number of episodes of diarrhea in a day, relieving and aggravating factors, other associated symptoms for diarrhea. Information on the urinary habits such as urine incontinence, hesitancy, dysuria, urgency, and increased frequency should also be included. Still on bowel and urinary habits, information on odor, color, and discomfort after or during a bowel movement should be included. Patients with pancreatic cancer often experience darkening of urine and stool lightening (Vincent, Herman & Goggins, 2011). Potential associated symptoms of abdominal pain such as vomiting and nausea should be established.
It is clear that the patient had a history of GI bleeding 4 years ago. Therefore, information on the absence or presence of blood in vomitus or stool should be included noting the color and smell. Since she is hypertensive and diabetic on medications, information on medication adherence should be included. It is also mandatory to include information on the occupation of the patient as this would help to determine possibilities of abdominal injury.
Additional Information that Should Be Included in the Documentation of Objective Data
Following the chief complaint of generalized abdominal pain, this patient needed a detailed physical and abdominal examination. Therefore information on the patient’s general appearance should be included which may be; sick-looking, in severe pain, lethargic, noting the patient’s mental status, gait, and nutritional status. Patients with pancreatic cancer are often cachectic and malnourished. Information on jaundice, pallor and skin pigmentation should be included. Anemia, jaundice and skin excoriation are characteristic findings in patients with pancreatic cancer (Halbrook & Lyssiotis, 2017). Jaundice may be associated with a non-tender, distended palpable gallbladder that is elicited using the Courvoisier sign, skin excoriation due to pruritus, acholic stool, and darkening of the urine.
Additional information would include may be obtained from inspection, percussion, palpation, and auscultation of the abdomen. On inspection, information on abdominal distension is necessary. In patients with pancreatic cancer, abdominal distension often acutely which is more painful. Information on the presence or absence of scars is also necessary. The presence of scars on the abdomen is an indicator for previous surgeries which would add on already available information to get a more accurate diagnosis (Ryan, Hong & Bardeesy, 2014). Besides, information on the presence or absence of visible distended veins on inspection should be included.
On palpation, information on whether the abdomen is soft, rigid, fluid-filled, tender, non-tender guarding or with rebound tenderness should be included. In guarding, patients tighten the muscles of the abdomen. Rigidity is highly suggestive of digestive juices, blood or bowel substances in the peritoneal cavity. Masses are suggestive of an aneurysm, tumors or a bowel that is obstructed. In patients with pancreatic cancer, characteristic findings include: a palpable intra-abdominal mass, peri-umbilical mass called Sister Mary Joseph node, ascites and non-tender palpable gallbladder (Oberstein & Olive, 2013). Information on the abdominal areas where there is increased tenderness on palpation is necessary in narrowing down to specific causes that relate to the clients clinical presentation that would guide the diagnostic, laboratory or radiological imaging studies to be conducted for the patient.
Whether the Assessment Is Supported by the Subjective and Objective Information
The assessment that is provided in this case denotes the presence of left lower quadrant pain and gastroenteritis. This assessment is fully supported by both the subjective and objective data. In the subjective data, the patient reported symptoms of diarrhea although without vomiting which is a major characteristic finding in gastroenteritis (Oberstein & Olive, 2013). Patients with Pancreatic cancer experience diarrhea due to the inability of the pancreas to release adequate pancreatic enzymes that help in the digestion of food. Therefore, the levels of pancreatic enzymes which are naturally produced are highly insufficient for digestion, resulting to malabsorption and thereafter diarrhea (Oberstein & Olive, 2013).
The other assessment was that of pain in the left lower quadrant which is partially supported by the symptom of generalized abdominal in the subjective data and fully supported with pos pain the left lower quadrant on abdominal examination in the objective data. The abdominal organs in the left iliac fossa include the ileum, rectum, left ureter and some parts of the colon. Since the patient reported no symptoms of diarrhea, the left lower quadrant pain was as a result of gastroenteritis in this case (Ryan, Hong & Bardeesy, 2014).
Most Appropriate Diagnostic Tests for This Case and How Results Would Be Used in Making A Diagnosis
In this case, some of the most appropriate diagnostic tests that would be used to make a diagnosis include: a complete blood count and a liver function test. It would also be necessary to perform a tumor markers test. A complete blood count would reveal a normochromic anemia and thrombocytosis which are major findings in patients with pancreatic cancer. A liver function test would indicate high levels of bilirubin, alkaline phosphatase, serum amylase and lipase which are an indicator for obstructive jaundice (Hallet, et al., 2015). The most commendable tumor marker test, in this case, would be the carbohydrate antigen 19-9whereby, in the case of pancreatic cancer, would be elevated to the levels of 100U/ml from the normal range of 33-37U/ML (Ryan, Hong & Bardeesy, 2014). The highly recommended imaging study for this case is the use of CT scan rather than MRI. An abdominal CT scan is able to image the entire pelvis and abdomen. The appearance of lower-density lesions on CT scan will support the diagnosis of pancreatic cancer.
Whether I Would Accept/Reject the Current Diagnosis
The current diagnosis for the patient in this case is pancreatic cancer as confirmed by the CAT scan. Clinically, patients with pancreatic cancer present with signs and symptoms of gradual onset of pain in the upper abdomen which radiates to the back, yellow coloration of the skin and sclera, diarrhea, unintended weight loss, and loss of appetite (Vincent, Herman & Goggins, 2011). Weight loss occurs as a result of the inability of the body to digest food due to a hindrance in the production of pancreatic juices for digestion of food or malabsorption that generally lead to diarrhea with stools that are greasy. The tumor also contributes to the difficulty to eat or causes discomfort after feeds (Halbrook & Lyssiotis, 2017). With regards to jaundice, the bile duct may be blocked leading to yellow coloration of the skin, sclera, dark colored urine and pale stools. The pancreas is located in the upper quadrant of the abdomen thus, patients with pancreatic cancer will often report on upper abdominal pain as a result of the tumor pressing on the abdominal nerves (Halbrook & Lyssiotis, 2017).
In this case, the examination of the skin and abdomen revealed no significant findings such as rigidity to suggest a mass, skin changes such as yellow pigmentation to suggests obstruction, pruritus, or pallor. To add on, the patient has no medical, social or familial history that increases his risk to pancreatic cancer. However, the patient presented with generalized abdominal pain, diarrhea and she reported that she was able to eat although with some minimal nausea afterwards. Besides, the pain was localized in the lower quadrant of the abdomen and this can be attributed to the fact that the patient was as a result of gastroenteritis. Therefore, I would accept the current diagnosis.
Possible Differential Diagnoses
Potential differential diagnoses, in this case, include: an abdominal aortic aneurysm, pancreatic lymphoma, intestinal ischemia, and gastric lymphoma. Cancer and Women’s and Men’s Health Essay Example.
References
Hallet, J., Law, C. H. L., Cukier, M., Saskin, R., Liu, N., & Singh, S. (2015). Exploring the rising
incidence of neuroendocrine tumors: a population‐based analysis of epidemiology, metastatic presentation, and outcomes. Cancer, 121(4), 589-597.
Halbrook, C. J., & Lyssiotis, C. A. (2017). Employing metabolism to improve the diagnosis and
treatment of pancreatic cancer. Cancer Cell, 31(1), 5-19.
Oberstein E P., & Olive O. P. K., (2013). Pancreatic cancer: why is it so hard to treat?
Therapeutic Advances in Gastroenterology 6(4):321-327.
Ryan, D. P., Hong, T. S., & Bardeesy, N. (2014). Pancreatic adenocarcinoma. New England
Journal of Medicine, 371(11), 1039-1049. Cancer and Women’s and Men’s Health Essay Example
Vincent A., Herman, J., & Goggins M., (2011). Pancreatic cancer. Lancet. 378(9791):607-620
