Case Study Example on Abdominal Assessment

This article is a case study example on abdominal assessment. Study it to learn how to write case study essays and gain insights into how you can get expert case study essay writing help.

The Assignment

Case Study Example on Abdominal Assessment

Assessment 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.
  

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 afterward.
• 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 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 a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence-based literature.
By Day 7

Case Study Example on Abdominal Assessment.

The Essay Solution

Case Study Example on Abdominal Assessment

Additional Information that Should Be Included in Subjective Data Documentation

Subjective data is information provided to a healthcare professional from a patient’s perspective. As a result, it covers the worries, sentiments, and perspectives gleaned via interviewees. The patient’s primary complaint in the presented case was widespread abdominal discomfort. Apart from asking about the pain’s intensity on a scale of 0-10, it’s also crucial to question the pain’s quality, whether it’s migratory or localized, if it’s increasing or decreasing in severity, and where it originates and radiates.

It should also be mentioned if the discomfort came on suddenly or gradually. The patient should be questioned about what she was doing when the discomfort began. It is impossible to overestimate the significance of finding any aggravating or alleviating variables for the pain. This information is critical in limiting down to some of the most likely diagnoses, according to Oberstein & Olive (2013).

Despite the fact that the patient mentioned diarrhea, further information on bowel and urine habits should be given. This covers the length and number of bouts of diarrhea in a day, alleviating and aggravating causes, and other diarrhea-related symptoms. Urinary behaviors such as urinary incontinence, hesitation, dysuria, urgency, and increasing frequency should all be documented.

Still, on the subject of bowel and urine habits, details about the odor, color, and pain experienced after or during a bowel movement should be given. Urine darkening and stool lightening are common symptoms of pancreatic cancer patients (Vincent, Herman & Goggins, 2011). It’s important to rule out any possible stomach discomfort symptoms like nausea and vomiting.

The patient clearly had gastrointestinal bleeding four years ago. As a result, information on the presence or absence of blood in vomitus or stool, as well as the color and smell, should be given. Information on medication adherence should be supplied since she is hypertensive and diabetic on medication. It is also necessary to provide information about the patient’s work since this will aid in determining the likelihood of abdominal damage.

Additional Information That Should Be Included in Objective Data Documentation

This patient required a thorough physical and abdominal examination after complaining of diffuse stomach discomfort. As a result, information on the patient’s overall appearance, such as sick-looking, in severe pain, sluggish, as well as the patient’s mental condition, gait, and nutritional status, should be provided. Pancreatic cancer patients are often cachectic and emaciated.

Jaundice, pallor, and skin pigmentation should all be mentioned. Anemia, jaundice, and skin excoriation are all common symptoms in pancreatic cancer patients (Halbrook & Lyssiotis, 2017). A non-tender, enlarged palpable gallbladder, skin excoriation owing to pruritus, acholic stool, and darkening of the urine are all symptoms of jaundice.

Additional information may be gained by abdominal examination, percussion, palpation, and auscultation. Information about abdominal distension is required during the examination. Abdominal distension is common in people with pancreatic cancer, and it is more uncomfortable. It is also vital to provide information on the existence or absence of scars. Scars on the abdomen are a sign of past operations, which may be used to supplement the information currently available to provide a more accurate diagnosis (Ryan, Hong & Bardeesy, 2014). Also provided should be information on the presence or absence of apparent bulging veins on examination.

When palpating the abdomen, note if it is soft, firm, fluid-filled, tender, non-tender guarding, or tender with rebound tenderness. Patients tense their abdominal muscles while guarding. Rigidity in the peritoneal cavity is very indicative of digestive juices, blood, or intestinal contents. Aneurysms, malignancies, and clogged bowels are all possible causes of mass.

A palpable intra-abdominal mass, peri-umbilical tumor termed Sister Mary Joseph node, ascites, and a non-tender palpable gallbladder are all common symptoms in individuals with pancreatic cancer (Oberstein & Olive, 2013). In order to narrow down to specific causes that relate to the client’s clinical presentation, information on the abdominal areas where there is increased tenderness on palpation is required. This information will guide the diagnostic, laboratory, and radiological imaging studies that will be performed on the patient.

Case Study Example on Abdominal Assessment.

Whether or not the subjective and objective data support the assessment

In this instance, the examination indicates the existence of left lower quadrant discomfort and gastroenteritis. Both subjective and objective evidence strongly support this conclusion. In the subjective data, the patient described symptoms of diarrhea but no vomiting, which is a common sign of gastroenteritis (Oberstein & Olive, 2013).

Diarrhea is a symptom of pancreatic cancer, which occurs when the pancreas is unable to produce enough pancreatic enzymes to aid digestion. As a consequence, the naturally generated pancreatic enzymes are inadequate for digestion, leading to malabsorption and, eventually, diarrhea (Oberstein & Olive, 2013).

The other evaluation was pain in the left lower quadrant, which is somewhat supported in the subjective data by the symptom of widespread abdominal pain and totally supported in the objective data by the discomfort in the left lower quadrant on abdominal examination. The ileum, rectum, left ureter, and various sections of the colon are among the abdominal organs found in the left iliac fossa. The discomfort in the left lower quadrant was caused by gastroenteritis in this instance since the patient had no signs of diarrhea (Ryan, Hong & Bardeesy, 2014).

Diagnostic Tests Most Appropriate for This Case and How Results Would Be Used in Diagnosis

A complete blood count and a liver function test are two of the most acceptable diagnostic procedures that would be performed to reach a diagnosis in this scenario. In addition, a tumor markers test would be required. A full blood count would demonstrate normochromic anemia and thrombocytosis, both of which are common in pancreatic cancer patients. High levels of bilirubin, alkaline phosphatase, serum amylase, and lipase, which are indicators of obstructive jaundice, might be detected by a liver function test (Hallet, et al., 2015).

The carbohydrate antigen 19-9, which, in the case of pancreatic cancer, would be increased to levels of 100U/ml from the normal range of 33-37U/ML, would be the most noteworthy tumor marker test in this scenario (Ryan, Hong & Bardeesy, 2014). CT scan rather than MRI is the highly recommended imaging investigation in this scenario. The whole pelvis and abdomen may be imaged with an abdominal CT scan. The presence of lower-density lesions on a CT scan will support a pancreatic cancer diagnosis.

Acceptance/Rejection of the Current Diagnosis

The patient’s latest diagnosis is pancreatic cancer, which was confirmed by the CAT scan. Pancreatic cancer patients show signs and symptoms such as a slow start of discomfort in the upper abdomen that spreads to the back, yellow skin and sclera, diarrhea, unintentional weight loss, and lack of appetite (Vincent, Herman & Goggins, 2011).

Weight loss is caused by the body’s inability to digest food owing to a blockage in the formation of pancreatic secretions for digestion or malabsorption, which usually results in diarrhea and oily stools. The tumor also makes eating difficult or causes pain after feedings (Halbrook & Lyssiotis, 2017).

When it comes to jaundice, the bile duct might get clogged, resulting in yellow skin, sclera, dark urine, and pale feces. Because the pancreas is positioned in the upper region of the abdomen, individuals with pancreatic cancer often have upper abdominal discomfort due to the tumor pushing on the abdominal nerves (Halbrook & Lyssiotis, 2017).

In this instance, there were no notable findings such as stiffness, which might indicate a mass, or skin abnormalities, such as yellow pigmentation, which could indicate blockage, pruritus, or pallor, which could indicate obstruction. Furthermore, the patient has no medical, social, or family history that would put him at an increased risk of pancreatic cancer.

The patient, on the other hand, appeared with broad stomach discomfort, diarrhea, and the ability to eat, although with some little nausea afterward. Furthermore, the discomfort was concentrated in the lower region of the abdomen, indicating that the patient was suffering from gastroenteritis. As a result, I’m willing to accept the existing diagnosis.

Case Study Example on Abdominal Assessment.

Differential Diagnosis Possibilities

An abdominal aortic aneurysm, pancreatic lymphoma, intestinal ischemia, and gastric lymphoma are all possible differential diagnoses in this instance.

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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

Case Study Example on Abdominal Assessment.