Abdominal Assessment Essay Assignment
Subjective portion and additional information to be included in the documentation.
In this case study the subjective data entails the feelings of the patient regarding generalized abdominal pain. Using a scale of 0-10, the clinician should enquire about the intensity of the pain along with whether it is localized or migratory (Jarvis,2018). In addition to the information about quantity of the pain, extra information on whether the pain was sudden or gradual should be included. Other important additional information that should be included in the documentation include what the patient was doing during the onset of pain, any changes in the appetite and dietary habits, the character, exacerbating, and relieving factors of the pain (Jarvis,2018). Abdominal Assessment Essay Assignment. c onsidering the patient states to have not taken any medications. It would also be important to include information about the last physical examination of the patient including the diagnostic test performed if any and the findings of the diagnostic studies. All this information is essential in having a better understanding of the patient’s condition.
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Objective portion and additional information to be included in the documentation.
Since the chief complain of the patient is generalized abdominal pain, there is a need to have a more thorough abdominal assessment. Information such as abdominal musculature observation, abdomen coloring, abdominal distention observation along with abdomen percussion should be documented after the abdominal examination (Jarvis,2018). The clinician should also ensure that findings are more detailed for accurate diagnosis. Apart from the hyperactive bowel sounds, other additional information including findings of the palpated sites such as the liver, assessment of abdominal reflexes, observations on rebound tenderness and performance of murphy’s signs should be included (Jarvis, 2018). All this information is critical to determine the causes that are similar to the symptoms of the patient which should guide on the diagnostics to be involved.
Assessment support by the subjective and objective information
The case assessment signifies lower quadrant pain presence along with gastroenteritis. This assessment is supported by subjective data where the symptoms of diarrhoea in the absence of vomiting and low-grade fever are reported by the patient forming the characteristic findings to support gastroenteritis findings. However, the objective data is deficient and pends further evaluation. Abdominal Assessment Essay Assignment
Most appropriate diagnostic tests and use of the results to make a diagnosis
For patients with recurring abdominal pain similar to this case, the following diagnostic tests should be done:
Accepting or rejecting the current diagnosis
The current diagnosis of gastroenteritis is acceptable although further assessment and testing is required to ascertain the diagnosis. Though the diagnosis of gastroenteritis can be achieved through use of subjective and objective data only, it is recommended that any the possible diagnosis is ruled out. Normally the common symptoms of gastroenteritis include diffuse abdominal pain that is crampy and is usually accompanied by diarrhoea, nausea, vomiting and fever (Reed, Woosley & Dellon ,2015). The patient in this case study reports to have low grade fever with nausea and diarrhoea without vomiting. Besides the patient has hyperactive bowel sounds a symptom that patients with gastroenteritis have.
The patient could be having various abdominal issues. The patient complains of diffuse abdominal pain accompanied with nausea and has hyperactive bowel sounds. Abdominal Assessment Essay Assignment. These symptoms can also point to, bowel obstruction, diverticulitis, or irritable bowel syndrome (IBS). Every condition needs particular diagnostic testing to have an accurate diagnosis.
Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: a clinical review. Jama, 313(9), 949-958.
Gore, R. M., Silvers, R. I., Thakrar, K. H., Wenzke, D. R., Mehta, U. K., Newmark, G. M., & Berlin, J. W. (2015). Bowel obstruction. Radiologic Clinics, 53(6), 1225-1240.
Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.
Reed, C., Woosley, J. T., & Dellon, E. S. (2015). Clinical characteristics, treatment outcomes, and resource utilization in children and adults with eosinophilic gastroenteritis. Digestive and Liver Disease, 47(3), 197-201.
Young-Fadok, T. M. (2018). Diverticulitis. New England Journal of Medicine, 379(17), 1635-1642. Abdominal Assessment Essay Assignment.
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.
Review the Episodic note case study.
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.—
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?—
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.—
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation—
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.— Abdominal Assessment Essay Assignment.