Advanced Health Assessment & Diagnostic Reasoning
Week 6 Case Study
Week 6: Assessment of the Abdomen and Gastrointestinal System ABDOMINAL ASSESSMENT 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: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Assignment 1: Lab Assignment: Assessing the Abdomen
Photo Credit: Getty Images/Hero Images
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.
To Prepare
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.
Learning Resources
Required Readings (click to expand/reduce)
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 6, “Vital Signs and Pain Assessment”
This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
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.
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”
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”
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”
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”
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 107, “X-Ray Interpretation: Chest (pp. 480–487)
Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520)
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Document: Midterm Exam Review (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)
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” (pp. 528–540)
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.
Required Media (click to expand/reduce)
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 instruc
Advanced Health Assessment and Diagnostic Reasoning
Case Study
Patient Information:
Initials: JR Age: 47 Sex: Male Race: Caucasian
Subjective Data
Chief Complaint: “My stomach hurts! I have diarrhea, and nothing seems to help.”
HPI: JR, 47 yo WM, with c/o of generalized acute abdominal pain for three days. Denies that he has taken medications. He rates the abdominal pain is a 5/10 today but at worst the pain has been a 9/10 during the initial onset of the abdominal pain. He reports that he is able to eat with some nausea afterward, denies vomiting.
Current Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
PMHx: HTN, Diabetes, hx of GI bleed 4 years ago
Soc Hx: Denies tobacco use; occasional ETOH, married, 3 children (1 girl, 2 boys)
Fam Hx: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
O.
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, positive pain in the LLQ on palpation
Diagnostics: None
1. Differential Diagnoses: LLQ abdominal pain: Gastroenteritis
Subjective Portion
The subjective portion shows that the health data is within the optimal range. The information is backed up by the chief complaint about diarrhea. The patient also complains of nausea and abdominal pain. He has taken no medication yet to relieve the condition. The complaint suggests that the digestive system is not functioning properly. Additionally, the subjective portion shows that the patient has hypertension and diabetes and is currently on medication. The hypertension is also suggested by the medication the patient is currently taking. The patient has no history of allergies, which could have triggered the infection. However, they have a history of a digestive tract problem which is gastrointestinal infection. The data requires further information to assess the condition critically.
Additional Information
The additional information is necessary for critically analyzing the scenario and diagnosing the problem. For example, the chief complaint should indicate the onset of nausea and diarrhea. The information about diarrhea should be accompanied by confirmation about whether there is blood in the stool. The condition could have been triggered after taking specific food at home, hotel or in an event. The diet of the patient for the last three days should also be provided. The diet will also reveal if the meals were taking together with other people and if they are also currently exhibiting similar symptoms. The patient should also describe their lifestyle which will be used to reveal the drinks they would have taken that triggered a stomach upset. Objective information should also capture whether the patient has experienced excessive thirst. The additional information will provide an opportunity to make an informed diagnosis or recommend further tests to be carried out (Dennly, 2019).
Objective Portion
The objective portion shows the current health condition of the patient especially using the vital signs. The body temperature is normal, the condition of the lungs is healthy as well as the skin. However, the abdomen has hyperactive bowel sounds which indicate the possibility of diarrhea, abnormal bowel movement or constipation. The bowel sounds indicate that it is necessary to get more information about the digestive tract especially through diagnostic tests such as CT scan or X-rays (Dennehy, 2019). Additionally, the patient has a high blood pressure of 160/86, but he is taking the medication. The weight of the patient also shows they could be overweight. The weight is a risk due to the high blood pressure and diabetes the patient is suffering from. Therefore, although the patient is complaining about nausea and diarrhea, it is important to refer them to a specialist who will check the progress and risk factors.
Additional Information
The document should include additional objective information to help a clinician make an accurate diagnosis. For instance, the clinician should record the general appearance of the patient. Descriptions such as alert and oriented, NAD, dull facial expression, and hygiene will be critical in the diagnosis. The general information will be used to describe if the patient is comfortable and unwell.
Subjective and Objective Information
The assessment is partially supported by the subjective and objective information presented in the documentation. The documentation is lacking critical information and thus the assessment may be inaccurate. The inaccuracy is due to other conditions that may present similar symptoms including diarrhea and nausea (Wood, 2018). The symptoms can be caused by cases of food poisoning. It is also important to know the meals the patient took the last three days, where they were prepared and the other people who ate the meals. It is important to reveal if the patient has eaten food or drinks that he does not frequently take. The patient should explain further the history of gastrointestinal bleeding four years ago. The explanation should elaborate if the condition has reoccurred and the circumstances surrounding the bleeding.
Additional information is also necessary to help rule out the conditions that cause similar symptoms. The conditions include inflammatory bowel disease, gastritis, viral infection, food poisoning, peptic ulcer, irritable bowel syndrome, and esophagitis. The conditions will be used in differential diagnosis to narrow down to one condition. The clinician thus requires additional subjective and objective information to help make an accurate diagnosis and avoid a possible misdiagnosis.
Diagnostic Tests
Diagnostic tests are necessary to provide additional information to a clinician to help them make a critical diagnosis. For example, a sample stool test is necessary to evaluate the virus or bacteria that could be upsetting the digestive system. A stool test is used to detect norovirus and rotavirus which can cause symptoms similar to gastroenteritis (Stanley, Moriarty & Cronin, 2016). The information about the viral or bacterial infection will help rule out other conditions. The patient may also require CT scans and sigmoidoscopy. The radiologic examination is used to examine the digestive tract and identify a possible inflammatory bowel disease. On the other hand, sigmoidoscopy will be used to examine abnormal cells along the digestive tract and ulcers since they cause similar symptoms such as nausea and diarrhea (Stanley, Moriarty & Cronin, 2016). An endoscopy can also be carried out to check the condition of the digestive tract. The focus is on the digestive tract due to the hyperactive bowel sounds that confirm the presence of abnormal activity in the bowels (Kelly, Liebenberg & Cohen, 2019). It is also important to take a blood test to check the presence of antibodies for gastrointestinal parasites (Kelly, Liebenberg & Cohen, 2019). The diagnostic tests will be used to provide information that can confirm the current diagnostic results of gastroenteritis or confirm another health condition.
Accept or Reject Diagnosis
The current diagnosis is unacceptable since critical tests are yet to be carried out. The assessment was carried out without adopting a comprehensive approach, especially on the diagnostic tests. The patient did also not provide information about the meals taken, where they were taken and who else took the meals and their current health condition. The diagnostic reasoning also did not involve differential analysis to help rule out conditions that present similar symptoms. On the other hand, patients with hyperactive bowel sounds will mostly be suffering from gastroenteritis (Dennly, 2019). However, there are other diseases that have symptoms such as nausea, abdominal pain, and diarrhea which the patient is complaining about. Therefore, to avoid any misdiagnosis more information is needed. For example, a CT scan or other radiological tests are necessary to check the state of the digestive tract (Dennly, 2019). The role of an advanced nurse is also to carry out advanced tests and to ensure they narrow down to one health condition that the patient is suffering from.
Differential Diagnosis
Differential diagnosis is necessary to help rule out conditions that may present almost similar symptoms. The symptoms presented by the patient suggest that the digestive tract has a problem, either a viral or bacterial infection (Stanley, Moriarty & Cronin, 2016). For instance, the hyperactive bowel sounds point to a possible problem with the digestive system. according to Wood (2018) is important to differentiate the specific condition of the patient from others with similar symptoms by carrying out advanced diagnostic tests. The three conditions that will be analyzed in the differential diagnosis include irritable bowel syndrome, bowel obstruction, and inflamed bowel disease. The three conditions present almost similar symptoms but with major differences (Dennehy, 2019). It is the responsibility of advanced nurses to carry out an in-depth analysis of a condition before prescribing medication.
• Irritable Bowel Syndrome (IBS) – Irritable bowel syndrome is a condition that affects the digestive tract especially the large intestines. Wood (2018) states that the symptoms of the disease include abdominal pain, diarrhea, bloating, and cramping. Patients suffering from irritable bowel syndrome have a normal bowel movement. The disease is triggered by alcohol or dairy products. It is important to carry out blood, stool tests or gluten tolerance to diagnose the condition (Wood, 2018). If the condition persists for 6-8weeks advanced nurses may require to carry out proctosigmoidoscopy to examine the rectum.
• Bowel obstruction – Bowel obstruction is a disease that affects the digestive tract causing various symptoms such as bloating, vomiting, and abdominal pain (Kelly, Liebenberg & Cohen, 2019). Patients can also experience loss of appetite and difficulty in passing gas. The condition can occur to a person of any age including newborns and elderly. It is prevalent among people who had surgery of the digestive system especially gastrointestinal surgery. It is mostly caused by colon cancer, hernia and inflamed intestine (Kelly, Liebenberg & Cohen, 2019). The obstruction causes frequent vomiting. The obstruction may be partial or complete. The diagnosis for the condition includes a CT scan, MRI, and X-ray.
• Inflammatory bowel disease – The condition leads to inflammation of the digestion tract. The inflammation causes loss of appetite, diarrhea, and abdominal pain (Stanley, Moriarty & Cronin, 2016). The condition is an umbrella name for other diseases such as Crohn and ulcerative colitis (Stanley, Moriarty & Cronin, 2016). Various diseases may also cause fever and anemia. The inflammation causes damage to the inner layer of the large intestine.
References
Dennehy, P. H. (2019). Infectious Gastroenteritis. Introduction to Clinical Infectious Diseases (pp. 157-168). Springer, Cham.
Holtmann, G. J., Ford, A. C., & Talley, N. J. (2016). Pathophysiology of irritable bowel syndrome. The Lancet Gastroenterology & Hepatology, 1(2), 133-146.
Kelly, T., Liebenberg, P., & Cohen, A. (2019). A rare case report of small bowel obstruction following colonoscopy. Journal of Surgical Case Reports, 2019(2), rjz049.
Stanley, E., Moriarty, H. K., & Cronin, C. G. (2016). Advanced multimodality imaging of inflammatory bowel disease in 2015: an update. World Journal of Radiology, 8(6), 571.
Wood, J. D. (2018). Neuropathophysiology of the irritable bowel syndrome. In Physiology of the Gastrointestinal Tract (pp. 1643-1668). Academic Press.
