Quantitative Methods of Inquiry
January 17, 2020
Schizophrenia Treatment
January 17, 2020

Episodic Note Case Study:

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: 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 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. 

· With regard to the Episodic note case study provided:

o Review this week’s Learning Resources, and consider the insights they provide about the case study.

o Consider what history would be necessary to collect from the patient in the case study.

o 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?

o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

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 the 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 as a
differential diagnosis for this patient. Explain your reasoning using at
least three different references from current evidence-based
literature.

Resource for references

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.

 

“Looking for a Similar Assignment? Get Expert Help at an Amazing Discount!”


Buy Custom Nursing Papers


Assessment of the abdomen and the gastrointestinal system was first posted on January 17, 2020 at 10:35 am.
©2019 "Assignment Hub". Use of this feed is for personal non-commercial use only. If you are not reading this article in your feed reader, then the site is guilty of copyright infringement. Please contact me at admin@bestessays.de

 

"Is this question part of your assignment? We Can Help!"

Essay Writing Service