Queen Essays

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Lab Assignment: Assessing the Abdomen

Riyaben Patel

Walden University

NURS-6512N

Dr. Benefield

July 5th 2023

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Introduction

The patient, a 65-year-old African American male, presented to the emergency

department with a two-day history of intermittent epigastric abdominal pain that radiates into his

back. Despite receiving proton pump inhibitors (PPIs) at a local Urgent Care, his pain has been

progressively worsening, and he experienced vomiting after lunch, prompting his visit to the

emergency department. The patient denied fever, diarrhea, or other symptoms associated with his

abdominal pain. This paper ideally aims to analyze the subjective and objective documentation

provided, identify missing information, and evaluate the assessment and diagnostic tests in order

to determine the most likely diagnosis.

CC: "My stomach has been hurting for the past two days."

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two-day history of

intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent

Care where was given PPIs with no relief. At this time, the patient reports that the pain has been

increasing in severity over the past few hours; he vomited after lunch, which led his to go to the

ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his

abdominal pain.

PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd, Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female

Objective:

VS: Temp 98.2; BP 91/60; RR 16; P 76.

HT 6’10”; WT 262lbs

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Heart: RRR, no murmurs

Lungs: CTA, chest wall symmetrical

Skin: Intact without lesions, no urticaria

Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.

Diagnostics: US and CTA

Assessment:

1. Abdominal Aortic Aneurysm (AAA)

2. Perforated Ulcer

3. Pancreatitis

Additional information that should be included in the Subjective documentation.

When calculated using the OLDCARDS approach, the HPI fails to account for pain's

nature, its causes, its relief, and its intensity. There is no description of the vomit's hue or texture.

The PMH is lacking information on the date of the HTN diagnosis and the status of resolution.

Hospitalization and surgery history prior to this section ID's creation are likewise absent.

Metoprolol dose and administration schedule are missing from the medications section. allergens

to food, the environment, and latex aren't covered in the section on allergens.

First-degree relatives are those inside the immediate family unit, such as parents,

grandparents, siblings, and children. Also included should be details on their age, whether they

are alive or dead, and their current physical condition. Include the ages and causes of death of

any dead family members. If the person is still living, their age and health status should be noted.

Addictive disorders, major depressive disorder, and other forms of mental illness should also be

included.

The social history mentions ETOH use, but does not specify how much or for how long

the patient has engaged in these activities. How often and how often a patient smokes, as well as

whether or not they utilize illicit drugs, should be stated in the smoking section. The patient's

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religious and cultural practices, as well as his or her ability to get medical treatment, should be

described here. Since the patient is complaining of stomach discomfort, it will be useful to have

dietary details, such as 24-hour consumption, on hand.

The Subjective Section of the Case Study is Missing a System Review. All symptoms,

positive and negative, affecting every organ system in the patient's body will be taken into

account. Due to the presence of GI symptoms, a thorough battery of subjective GI inquiries,

including: Disorders of the gastrointestinal tract that are persistent or in the past? Acid reflux or

pain below the breastbone? Pain in the belly? Trouble chewing or swallowing? Does it hurt to

swallow? Diarrhea or Nausea? Bowel distention or bloating? Skin discoloration (jaundice)?

Hematemesis, or the vomiting of blood? Stools that look like tar? Pooping blood? Constipation?

Alterations in bowel habits, such as diarrhea.

Patients lack necessary vaccines, such as hep A and hep B.

Additional information that should be included in the Objective documentation.

There is a lack of a holistic evaluation of the patient's overall condition. There is a lack of

oxygen saturation and body mass index in the vital signs section. In order to screen for

gastrointestinal illnesses common among foreign travelers, it is important to ask about any recent

trips. Any Jaundice from cholestasis may be detected in a physical examination by looking for

yellowing of the skin. Changes in urine color should be noted in the genitourinary segment, as

they may indicate the presence of cholestasis, a condition characterized by the renal excretion of

direct bilirubin from the blood.

The patient's complaints of stomach discomfort and vomiting need a complete evaluation

of the gastrointestinal system. The results of auscultation in all four quadrants, percussion in all

four quadrants, palpation in all four quadrants, and observation and inspection of the abdomen

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for form, scars, color, symmetry, and atypical protrusions are all necessary components of this

evaluation. The color of one's feces is an indicator of cholestasis, thus keeping an eye out for

pale stools is important. The possibility of internal bleeding is evaluated by seeing blood in the

stool. This evaluation must consider any changes in appetite, diet, or overall food consumption.

The missing laboratory findings are crucial for assessing organ performance.

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

1. Alcohol abuse is indicative of pancreatitis because it causes the typical symptoms of the

disease, such as epigastric pain that spreads to the back and nausea and vomiting (Hamm,

2021). Pancreatitis may be confirmed with further testing if amylase and/or lipase values

are three times the upper limit for their range. This diagnosis should also be confirmed by

the CT (Hamm, 2021).

2. The major risk factor of smoking two years ago lends credence to AAA. Smoking history

is also associated with an increased risk for AAA, albeit this risk declines with time. after

quitting smoking (Legg & Legg, 2016). Pain in the back, abdomen, flanks, buttocks,

scrotum, legs, and groin is the most typical symptom of a non-ruptured AAA. It is usually

only upon close inspection that this discomfort becomes apparent. A throbbing sensation

around the belly button is possible. In addition to a rapid heart rate, dizziness upon

standing, syncope, unconsciousness, cold sweats, nausea, and vomiting are all typical

AAA symptoms. Hypovolemic shock, characterized by hypotension, cyanosis, skin

mottling, and impaired mental state, may arise from internal bleeding caused by a

rupturing AAA. These signs are alarming since rapid circulatory collapse accounts for the

deaths of more than half of individuals with a ruptured AAA (Legg & Legg, 2016). The

patient in this case seems stable and does not have many of the classic indications of a

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AAA, thus that diagnosis is not warranted. Because of the symptoms, this diagnosis must

also confirm whether or not the AAA is raptured. The vast majority of AAA cases are

detected inadvertently and show no symptoms at all (Legg & Legg, 2016). A CT scan

with contrast is the imaging of choice for this diagnosis, unless the patient is pregnant or

has a known allergy to contrast.

3. There is no evidence, either subjective or objective, to support the diagnosis of perforated

ulcer. Abdominal pain, tachycardia, and abdominal stiffness are the typical triad signs of

a ruptured peptic ulcer. The patient does not have tachycardia or abdominal rigidity. In

addition, the patient does not currently take any NSAIDS or steroids, making smoking

history the sole risk factor for PUD (Chung & Shelat, 2017).

Appropriate diagnostic tests for this case, and how would the results be used to make a

diagnosis?

Abdominal discomfort may be caused by a number of medical issues, and several

diagnostic procedures may be required to narrow down the possibilities. Lab tests of blood,

urine, feces, and enzymes may be used as a diagnostic adjunct to the patient's medical history

and physical exam. Abdominal problems may be detected by imaging testing as well. Diagnostic

procedures for this patient's stomach discomfort include:

1. The electrocardiogram (EKG), which would reveal any cardiac abnormalities and rule out

ischemia.

2. Fecal Occult Blood Test: Stool samples may be tested for the presence of blood using a

fecal occult blood test. A positive bac = k test suggests internal bleeding, which may be

caused by polyps, hemorrhoids, diverticulosis, ulcers, colitis, or even colon cancer

(MedlinePlus, n.d.).

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3. Stool sample and blood tests for things like magnesium and phosphorus levels and

complete blood count. In the absence of these, an infection cannot be ruled out. Since the

patient reports recurrent diarrhea, the CMP may assess the kidneys', liver's, and

electrolytes' current condition.

4. Liver Enzymes/Hepatic Function Test-The health of one's liver may be gauged by doing

these tests. This test will show whether the liver is not properly filtering the blood, which

might indicate severe stomach discomfort. The liver's hepatic lobes are located in the

epigastric area; hence this is significant.

5. Ultrasound of the abdomen –Abdominal ultrasound is an imaging method that does not

cause any discomfort and provides a clear picture of the kidneys, liver, gall bladder,

spleen, and pancreas, all of which are located in the abdomen.

6. Abdominal X-rays may reveal the source of abdominal discomfort, such as gas,

constipation, or kidney stones.

7. Pancreatitis may be diagnosed by CT of the abdomen (Hamm, 2021).

8. Considering the expense, a pelvic exam would be scheduled only if the first two tests

came back positive.

Would you reject/accept the current diagnosis? Why or why not?

The patient's symptoms more closely match those of acute pancreatitis, which was likely

precipitated by the patient's heavy alcohol consumption. The patient's vital signs are normal,

while they would be severely impaired in the event of a AAA.

Three possible differential diagnosis for this patient. Explain your reasoning using at least

three different references from current evidence-based literature.

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1. Cholelithiasis happens when there is a blockage in the bile ducts or the cystic duct. Pain

in the upper right abdominal region or epigastric region that may radiate to the right side

of the back may be present, along with nausea, vomiting, and a high temperature (NCBI,

2021).

2. Gastritis. Heavy alcohol consumption is a frequent contributor. Nausea, vomiting, and

discomfort in the upper abdomen are prominent signs. MedlinePlus (n.d.) says these

symptoms are comparable to those experienced by this patient. Endoscopic examination

of the stomach, complete blood count labs to rule out anemia, and a stool occult check to

detect bleeding in the stomach as a result of gastritis are all necessary diagnostic

procedures (MedlinePlus, n.d.).

3. Cholecystitis is gallbladder inflammation. Pain in the upper right quadrant (biliary colic)

that worsens with time and sometimes travels to the back is a symptom of a more serious

condition. The severity of gallbladder neck blockage determines the occurrence of

jaundice. After eating a substantial, fatty meal, the attack often occurs. Over time, the

discomfort increases to the point where it causes moderate upper-right stomach distress

or persistent pain (Tirumala & Ramasubbaiah, 2019). Calcified gallstones may be seen on

an abdominal ultrasound, and an increased white blood cell count can be shown in lab

testing (Merck Manual 2021).

Conclusion

In conclusion, the subjective documentation in this case study lacks crucial details

regarding pain characteristics, triggers, and relief, as well as a description of the vomit's

appearance. Additionally, important information such as the HTN diagnosis date, past

hospitalizations, and surgeries are missing. The objective documentation requires additional vital

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signs, information on recent trips, and a comprehensive evaluation of the gastrointestinal system.

The assessment provided suggests potential diagnoses of pancreatitis, abdominal aortic aneurysm

(AAA), and perforated ulcer. However, the subjective and objective information does not support

the diagnosis of AAA or perforated ulcer. Further diagnostic tests, including lab tests and

imaging studies, are necessary to confirm or rule out the suspected diagnoses. A comprehensive

evaluation and complete documentation will aid in providing accurate and effective medical care

for the patient's abdominal pain.

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References

Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer – an update. World journal of

gastrointestinal surgery, 9(1), 1–12. https://doi.org/10.4240/wjgs.v9.i1.1

Hamm, R. G. (2021). Acute Pancreatitis: Causation, Diagnosis, and Classification Using

Computed Tomography. Radiologic Technology, 93(2), 197CT–219CT.

Legg, J. S., & Legg, L. M. (2016). Abdominal Aortic Aneurysms. Radiologic Technology, 88(2),

145–165 Medlineplus. (n.d). Fecal Occult Blood Test (FOBT).

https://medlineplus.gov/lab-tests/fecal-occult-bloodtest-fobt/

MedlinePlus. (n.d.). Gastritis. https://medlineplus.gov/ency/article/001150.htm

Merck Manual. (2021). Acute Cholecystitis.

https://www.merckmanuals.com/professional/hepatic-andbiliary-disorders/gallbladder-

and-bile-duct-disorders/acute-cholecystitis#v9109744

NCBI. (2021).Cholelithiasis. https://www.ncbi.nlm.nih.gov/books/NBK470440/

Tirumala, V. R. M. M., & Ramasubbaiah, R., MD. (2019). Cholecystitis. Magill’s Medical Guide

(Online Edition).