NURS 6512 Week 6 Assignment 1: Advanced Health Assessment and Diagnostic Reasoning Assessing the Abdomen Paper

NURS 6512 Week 6 Assignment 1: Advanced Health Assessment and Diagnostic Reasoning Assessing the Abdomen Paper

A white male aged 47 presents with diarrhea as well as abdominal pain. Upon examination a soft abdomen with left lower quadrant (LLQ) pains is noted accompanied with hyperreactive bowel sounds is noted. Gastroenteritis and the LLQ pain mark the differentials. The purpose of this paper is to analyze the SOAP note and discuss the likely differential diagnoses.

Subjective Portion

The HPI should capture the nature of the diarrhea including the color, bloody, watery or malodorous. Other symptoms linked to diarrhea and LLQ should also be captured. This should also entail accelerants and decelerates of the symptoms. Further details should capture immunization history as well as historical surgeries. The subjective also lacks a review of system (ROS), which is crucial in eliciting other patient symptoms in every body system that was not given in the PHI.

Objective Portion

This SOAP note should also capture results from palpation, auscultation, percussion and inspection of the abdomen. Inspection findings should include the abdomen’s symmetry, scars, respiratory movements, and pigmentation (Mealie et al., 2021). The auscultation findings should also include the presence of friction rubs and venous hum. Percussion findings should include the liver span, spleen size, kidney, and stomach findings. The findings should also include if there was muscle guarding or rebound tenderness.

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Assessment Portion

Both subjective and objective angles apply in this case as the pain in the LLQ is objective on the presence of pain and location, but may not be supported by a subjective angle as the patient complained of generalized pain in the abdominal area. The abdominal pain and diarrhea support subjective data for gastroenteric which is also supported by the abdominal pain and hyperreactive bowel sound as objective data. (Orenstein, 2020).

Appropriate Diagnostic Tests

Appropriate diagnosis would include conducting abdominal ultrasound, microscopic analysis of the stool as well as complete blood count. A stool microscopy result will help establish if the cause of diarrhea is bacterial, viral, or protozoan, which will guide the treatment plan (Orenstein, 2020). The CBC results will establish if there is an underlying infection which will guide the diagnosis and treatment. Lastly, the abdominal ultrasound results will help identify the cause of the LLQ pain and develop a diagnosis and treatment plan (Vaghef-Davari et al., 2019).

Diagnosis

LLQ pain is not an appropriate diagnosis since it is a physical sign that should guide the diagnosis, and I would therefore reject it. Gastroenteritis is more likely to be the diagnosis because the patient presents with abdominal pain and diarrhea. Differential diagnosis may include:

1. Viral Gastroenteritis: Clinical features of viral GE include non-bloody watery diarrhea, anorexia, nausea, vomiting, malaise, and low-grade fever. The symptoms on the abdomen include mild tenderness and hyperreactive bowel sounds. This becomes a differential considering abdominal tenderness, pain in the abdomen, nausea and hyperreactive bowel syndrome.
2. Acute Diverticulitis: Clinical features include nausea, vomiting, LLQ pain, diarrhea/constipation, fever, abdominal tenderness, and masses in case of an abscess. Key results include nausea, diarrhea and pain in the LLQ which are positive (Swanson & Strate, 2018).
3. Giardiasis: Clinical features of Giardiasis present in the patient include diarrhea, abdominal pain, nausea, and hyperactive BS. It is a differential based on positive diarrhea, nausea, and abdominal pain (Leung et al.., 2019).

Conclusion

Further information to immunization and historical surgery, the HPI should include more subjective information. Results from percussion, inspection, palpation and auscultation should offer the objective angle. Abdominal ultrasound, microscopy of stool and complete blood count should be the appropriate diagnosis. Viral gastroenteritis, giardiasis as well as acute diverticulitis mark the differential diagnosis.

References

Leung, A., Leung, A., Wong, A., Sergi, C. M., & Kam, J. (2019). Giardiasis: An Overview. Recent patents on inflammation & allergy drug discovery, 13(2), 134–143. https://doi.org/10.2174/1872213X13666190618124901

Mealie, C. A., Ali, R., & Manthey, D. E. (2021). Abdominal Exam. In StatPearls. StatPearls Publishing.

Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1

Swanson, S. M., & Strate, L. L. (2018). Acute Colonic Diverticulitis. Annals of internal medicine, 168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010

Vaghef-Davari, F., Ahmadi-Amoli, H., Sharifi, A., Teymouri, F., & Paprouschi, N. (2019). Approach to Acute Abdominal Pain: Practical Algorithms. Advanced journal of emergency medicine, 4(2), e29. https://doi.org/10.22114/ajem.v0i0.272

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NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Week 6 – The Episodic note case study: Abdominal Assessment
Review the Episodic note from the case study that you have been provided for this week’s Assignment.
ABDOMINAL ASSESSMENT
Subjective:
• 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 3 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 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: 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.

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.

This should be written as a narrative/paragraph only!
DO NOT rewrite a SOAP note. Tell me what’s wrong with the Episodic SOAP Note, by responding to the 5 statements/questions above.
Read the SOAP note for Abdominal Assessment, do this in paragraph form.
Use subheadings for the 5 Statements/questions. These are from the Rubric.
PLEASE DO NOT REWRITE THIS SOAP NOTE! It will lead to High Safe Assign Scores!
Utilize Safe Assign Drafts for originality report before final submission.
Utilize at least 5 scholarly , peer reviewed sources within 5 years.

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NURS_6512_Week_6_Assignment_1_Rubric

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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.–

Levels of Achievement:

Excellent 10 (10.00%) – 12 (12.00%)

Good 7 (7.00%) – 9 (9.00%)

Fair 4 (4.00%) – 6 (6.00%)

Poor 0 (0.00%) – 3 (3.00%)

Analyze the objective portion of the note. List additional information that should be included in the documentation.–

Levels of Achievement:

Excellent 10 (10.00%) – 12 (12.00%)

Good 7 (7.00%) – 9 (9.00%)

Fair 4 (4.00%) – 6 (6.00%)

Poor 0 (0.00%) – 3 (3.00%)

Is the assessment supported by the subjective and objective information? Why or why not?–

Levels of Achievement:

Excellent 14 (14.00%) – 16 (16.00%)

Good 11 (11.00%) – 13 (13.00%)

Fair 8 (8.00%) – 10 (10.00%)

Poor 0 (0.00%) – 7 (7.00%)

What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?–

Levels of Achievement:

Excellent 18 (18.00%) – 20 (20.00%)

Good 15 (15.00%) – 17 (17.00%)

Fair 12 (12.00%) – 14 (14.00%)

Poor 0 (0.00%) – 11 (11.00%)

• Would you reject or accept the current diagnosis? Why or why not?
  ·   Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.–

Levels of Achievement:

Excellent 23 (23.00%) – 25 (25.00%)

Good 20 (20.00%) – 22 (22.00%)

Fair 17 (17.00%) – 19 (19.00%)

Poor 0 (0.00%) – 16 (16.00%)

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.–

Levels of Achievement:

Excellent 5 (5.00%) – 5 (5.00%)

Good 4 (4.00%) – 4 (4.00%)

Fair 3 (3.00%) – 3 (3.00%)

Poor 0 (0.00%) – 2 (2.00%)

Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–

Levels of Achievement:

Excellent 5 (5.00%) – 5 (5.00%)

Good 4 (4.00%) – 4 (4.00%)

Fair 3 (3.00%) – 3 (3.00%)

Poor 0 (0.00%) – 2 (2.00%)

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.–

Levels of Achievement:

Excellent 5 (5.00%) – 5 (5.00%)

Good 4 (4.00%) – 4 (4.00%)

Fair 3 (3.00%) – 3 (3.00%)

Poor 0 (0.00%) – 2 (2.00%)

Name:NURS_6512_Week_6_Assignment_1_Rubric