Lab Assignment: Assessing the Abdomen
Lab Assignment: Assessing the Abdomen
Lab Assignment: Assessing the Abdomen
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Week 6 Assessment
This paper is an analysis of a SOAP note involving LZ. The paper explores the subjective and objective portions to determine the information that should be added. It also examines if subjective and objective data support the assessment. The paper also explores the diagnostic investigations and differential diagnoses that should be considered for the patient.
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Analysis of the Subjective Portion
Accurate and detailed information is important for the development of an appropriate diagnosis for LZ. The obtained information comprises subjective and objective data. The subjective data obtained from LZ is not detailed enough to guide the development of an accurate diagnosis. The subjective data provides information about the stomach hurting but fails to quantify the pain. The patient should have provided additional information about the character of the pain such as if it is burning, stinging, or sharp. The patient should also be asked about her dietary habits for the past few days. The information will enable the determination of whether the health problem is due to food poisoning or a different pathology. The patient should also be asked for information about bowel movements. Information that includes any history of diarrhea, bloating or passage of blood-stained stool should be obtained.
The history of the current problem should also be extensive. Information about the alleviating and exacerbating factors should be obtained. The patient has provided information that he vomited after lunch. However, detailed information about the quantity and color of the vomitus has not been obtained. Vomitus stained with blood could indicate gastric bleeding. The patient should have also been asked about the location of the abdominal pain. Left or right epigastric abdominal pain radiating to the back would have guided the determination of whether the problem is attributed to factors such as left or right-sided pancreatitis.
Analysis of the Objective Portion
The objective portion of the SOAP note also lacks detailed information that would guide the development of an accurate diagnosis for the patient. One of the objective data that should be included in the SOAP note is the general appearance of the patient. Information such as the dressing and that related to whether the patient is restless, anxious, tired, underweight, or overweight should be captured in the objective assessment portion. The information is used to identify risk factors such as obesity in the case of gastric conditions that include gastroesophageal reflux disease. The documentation should also include the patient’s response to questions. The information will enable the provider to determine if the patient is oriented to self, others, and space or not. A comprehensive review of systems also lacks in the objective portion of the assessment. Accordingly, a detailed, and systematic review of systems should be done to identify the systems that may be contributing to or affected by the problem. The objective portion also failed to incorporate other approaches of physical examination to the system affected by the abdomen. The portion lacks information about auscultation and percussion. The information would have guided the determination of the potential cause of the client’s problem.
Whether Objective and Subjective Information support Assessment
Objective and subjective information partly support LZ’s assessment. Subjective data refers to the information that healthcare providers acquire from the patients about their experiences with a disease or health problem. The information provides the basis for patient assessment and the development of accurate diagnoses. Healthcare providers obtain objective data using methods of physical assessment, laboratory, and diagnostic investigations. The techniques of the physical examination include observation, palpation, auscultation, and percussion. Partial subjective and objective information has been used to reach the client’s diagnosis. Examples of subjective data in the SOAP note include current complaints, history of the presenting illness, family history of chronic illnesses, and allergies. The objective data in the SOAP note include vital signs, auscultation of the cardiovascular, and diagnostics. The subjective and objective information obtained from the client is inadequate. It does not consider aspects of patient assessment that include comprehensive physical examination and acquisition of subjective data related to the health problem.
Diagnostic Tests
One of the diagnostic tests that should be performed to determine LZ’s problem is a blood test. Blood tests to determine levels of lipase and amylase levels should be done. An elevation of these enzymes indicates pathologies that include pancreatitis. The levels of serum amylase often rise within 4 to 8 hours of the onset of symptoms, peak at 24 hours, and normalize after 8-14 in case of pancreatic involvement. A blood test should also be done to determine glucose levels. Hyperglycemia may indicate involvement of the pancreas. Blood tests are also recommended to determine the levels of lipids and signs of infection by conducting a complete blood count.
The other diagnostic investigation needed for LZ is imaging tests. Radiographic investigations such as contrast-enhanced CT scan are the most accurate diagnostic that can be used to determine the client’s actual problem. The scan enables the elimination of other potential causes of acute abdominal pain, determination of complications, and severity of the underlying cause. An ultrasound may also be performed in case of the absence of a contrast-enhanced CT scan. It provides visualization of the internal organs and the involved pathologies. Magnetic resonance cholangiopancreatography may also be done to determine the involvement of organs that include the gallbladder, pancreas, and bile ducts in the disease process. Endoscopic ultrasound may also be recommended to visualize the gastric structures and organs that may be contributing to the problem.
Differential Diagnoses
I will reject the diagnosis of the patient with an abdominal aortic aneurysm. The client has features that closely resemble those associated with pancreatitis. Therefore, the following are the three potential causes of LZ’s problem:
Pancreatitis: Pancreatitis is a condition that arises from the localized destruction in the systemic inflammatory and pancreas response. Patients develop the condition due to risk factors that include trauma, smoking, drug use, gallstones, hypertriglyceridemia, viral infections, and hypercalcemia. Patients suffering from pancreatitis experience symptoms that relate to those of LZ. They include moderate to severe epigastrium pain accompanied by anorexia, nausea, and vomiting. The biliary etiology of pancreatitis has sharp pain that radiates to the back while that associated with toxicologic and metabolic causes has dull, generalized pain (Gapp & Chandra, 2022; Jung et al., 2018). Therefore, pancreatitis is the primary diagnosis for the patient.
Cholecystitis: Cholecystitis is the secondary diagnosis that should be considered for LZ. Cholecystitis is the inflammation of the gall bladder. Gallstone obstruction is the leading cause of gallbladder obstruction. Cholecystitis predisposes patients to complications that include biliary colic, choledocholithiasis, and perforation. Patients suffering from cholecystitis present to the hospital with symptoms that relate to those being experienced by LZ. They include epigastric pain or pain in the right upper quadrant of the abdomen radiating to the back. The accompanying symptoms include nausea and vomiting (Shian & Larson, 2018). Patients also experience fatty food intolerance, which can vary in patients.
Peptic Ulcer Disease: Peptic ulcer disease is the other differential that should be considered in this case study. Peptic ulcer disease is characterized by the development of ulcers in the gastric mucosa or walls. Factors such as smoking, alcohol abuse, and the use of nonsteroidal anti-inflammatory drugs increase the risk of patients being affected by the disease. Patients experience symptoms that include burning pain in the right upper quadrant of the abdomen, pain relieved by food, nausea, vomiting, bloating, and heartburn (Grigorian et al., 2019). Some of the symptoms are closely related to those of LZ. Therefore, peptic ulcer disease should be ruled out in the management process.
Conclusion
In summary, the subjective and objective information in the SOAP note is inadequate. It requires additional information that would guide the development of an accurate diagnosis and treatment plan. LZ’s assessment is supported partially by subjective and objective information. Therefore, the proposed differentials should be considered in the treatment process.
References
Gapp, J., & Chandra, S. (2022). Acute Pancreatitis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK482468/
Grigorian, A., Lin, M. Y. C., & de Virgilio, C. (2019). Severe Epigastric Pain with Nausea and Vomiting. Surgery, 227–237. https://doi.org/10.1007/978-3-030-05387-1_20
Jung, J. Y., Na, J. U., Han, S. K., Choi, P. C., LEE, J. H., & Shin, D. H. (2018). Differential diagnoses of magnetic resonance imaging for suspected acute appendicitis in pregnant patients. World Journal of Emergency Medicine, 9(1), 26–32. https://doi.org/10.5847/wjem.j.1920-8642.2018.01.004
Shian, B., & Larson, S. T. (2018). Abdominal Wall Pain: Clinical Evaluation, Differential Diagnosis, and Treatment. American Family Physician, 98(7), 429–436.
Question Description
Question Description
Assignment 1: Lab Assignment: Assessing the Abdomen
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.
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.
Assessment of the Abdomen and Gastrointestinal System
ABDOMINAL ASSESSMENT
SEE CASE STUDY BELOW
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, hyperactive bowel sounds, pos pain in the LLQ
Diagnostics: None
Assessment:
Left lower quadrant pain
Gastroenteritis
PLAN:
Develop an 8- to 10-slide PowerPoint presentation in which you:
Describe the history and evolution of databases. Address each of the following:Flat files
Early data management systems
Relational database systems
NoSQL
Compare open source database systems to commercial database systems.
Analyze the benefits and challenges of open source database systems and commercial database systems. Be specific and provide examples.
Analyze the use of databases as the foundation for health-related information systems. Be specific and provide examples.
Provide references in APA style at the end of your presentation—the reference slide or slides do not count toward your assignment total.Provide Retrieved from URL if it is an online reference
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
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