A male went to the emergency room for severe mid-epigastric 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.
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.
Resources
- Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 18, “Abdomen”
In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.
- Chapter 18, “Abdomen”
- Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. - Chapter 3, “Abdominal Pain Download Chapter 3, “Abdominal Pain”
This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis. - Chapter 10, “Constipation”Download Chapter 10, “Constipation”
The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests. - Chapter 12, “Diarrhea”Download Chapter 12, “Diarrhea”
In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform. - Chapter 29, “Rectal Pain, Itching, and Bleeding”Download Chapter 29, “Rectal Pain, Itching, and Bleeding”
This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies. - Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
These sections below explain the procedural knowledge needed to perform gastrointestinal procedures. - Chapter 115, “X-Ray Interpretation of Abdomen” Download “X-Ray Interpretation of Abdomen”(pp. 514–520)
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
Assessment of the Abdomen and Gastrointestinal System – Week 6 (14m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/Links to an external site.
- LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
- Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”
This chapter explores the health assessment processes for the abdomen, perineum, anus, and rectosigmoid. This chapter also examines the symptoms of many conditions in these areas.
- Chapter 10, “The Urinary System”
In this chapter, the authors provide an overview of the physiology of the urinary system. The chapter also lists symptoms and conditions of the urinary system.
- Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”
- Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V. (2021). Changing paradigms in the management of acute uncomplicated diverticulitisLinks to an external site.. Scandinavian Journal of Surgery, 110(2), 180–186. https://doi.org/10.1177/14574969211011032
- Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain in the elderly patient: Point-of-care ultrasound diagnosis of small bowel obstructionLinks to an external site.. Clinical Practice and Cases in Emergency Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029
