ABDOMINAL ASSESSMENT
queen b 1
abdominalcasestudy1.docx6
Abdominal Case Study
Name
Institution Affiliation
Course Code and Name
Professor’s Name
Date
Abdominal Case Study
Additional Subjective Data
The patient's stomach pain is described in a hazy manner. He omitted to mention the particular area of his stomach pain in his description. He failed to convey the anguish he is experiencing while ranking it on a scale of 0 to 10. Is the discomfort acute, cramping, hurting, shooting, stabbing, or throbbing in nature? When the discomfort first began, what was the patient doing? Are there any foods that make your discomfort worse or make it flare up? When the pain first begins, how long does it last? Is there anything that can help, such as belching or defecating? Is there a problem with the patient's urination? To complete a proper examination, the physician requires more information from the patient regarding the principal complaint and the subjective review of systems.
Reviewing Systems from a Personal Perspective: There is no weight loss, fever, chills, weakness, or exhaustion, according to the general assessment. Visual loss, impaired vision, double vision, or yellow sclera are not present in the eyes. Hearing loss, sneezing, congestion, runny nose, or sore throat are not current. There is no rash or irritation on the skin. Cardiovascular is a term that describes how the heart and blood vessels work together. There is no chest pain, pressure, or discomfort. There were no palpitations or edema. Shortness of breath, cough, or sputum is not present in the respiratory system. There is abdominal pain with nausea in the GIT. He denies having vomited. He claims he's been suffering from a lot of diarrhea. Remarks on the genitourinary system include: Denies having any urinary problems. According to the neurological data, there was no headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.
There is no difference in bowel or bladder control. The Musculoskeletal data include the following: There is no muscular, back, joint, or stiffness. There is no anemia, bleeding, or bruising, according to the hematologic material. There are no swollen nodes in the lymphatic. There has been no splenectomy in the past. There is no history of depression or anxiety, according to psychiatric statistics. There have been no instances of sweating, cold, or heat intolerance, according to endocrinologic comments. There isn't any polyuria or polydipsia. Allergy is a detailed record of allergies: no asthma, hives, eczema, or rhinitis in the past.
Additional Objective Data
In addition to what has already been assessed, an advanced practice nurse must investigate several different systems to complete a thorough assessment of an abdominal problem. To rule out an incarcerated hernia or testicular torsion, the physician must examine the patient's groin area (Dains et al., 2016). The provider should also check tenderness in the flanks. A kidney stone can cause flank pain. To rule out sexually transmitted infections (STIs) and prostatitis, males should have genital and prostate examinations. The advanced practice nurse must also look for Frank's blood or fecal occult blood. The presence of blood may signify an acute or malignant condition. Because abdominal pain can originate from various sources, the doctor should also check the lungs, heart, head and neck, and musculoskeletal system (Dains et al., 2016).
Available Evidence Support with the Current Diagnosis
Current evidence does not support the diagnosis of gastroenteritis. To accomplish a proper assessment, the advanced practice nurse requires extra subjective and objective information. In addition, diagnostic testing should be undertaken to rule out any other possibilities.
Appropriateness of the Current Diagnosis
Without further evaluation and testing, the current diagnosis is unacceptable. While only subjective and objective evaluation data can be used to diagnose gastroenteritis (Dains, Bauman, Scheibel, 2015), the advanced practice nurse must rule out any other probable diagnoses. Gastroenteritis is characterized by widespread, cramping stomach pain followed by nausea, vomiting, diarrhea, and fever. The patient is afebrile and has nausea and diarrhea but has not reported any vomiting to the provider. According to Dains et al., the patient with gastroenteritis will have hyperactive bowel noises, which our patient does. Gastroenteritis typically goes away on its own and does not require any diagnostic tests.
Appropriate Diagnostic Tests
To adequately manage the patient, tests are performed to determine the exact origin of the problem. A computed tomography scan is completed to see if there are any lesions or anomalies in the abdomen. If the causal organism is present, a stool test for culture and sensitivity is recommended.
Conditions That Might Be Diagnosed as a Different Diagnosis
The patient could be suffering from a variety of stomach problems. The patient has complained of nausea and diarrhea, as well as having hyperactive bowel sounds. Ureterolithiasis, bowel blockage, or irritable Bowes syndrome are all possible causes of these symptoms. To make a correct diagnosis, each ailment necessitates thorough diagnostic testing. Kidney stones form in the ureters, causing ureterolithiasis. The patient describes a rapid onset of painful intermittent colicky discomfort that can become persistent (Dains et al., 2016). The pain starts in the lower abdomen and spreads to the flank and groin. Nausea, vomiting, abdominal distention, chills, and fever are all symptoms of ureterolithiasis (Dains et al., 2016). Urinary frequency and hematuria may also be present. A urinalysis can be used to evaluate the pH of the urine, and the presence of crystals can aid in determining the stone's composition. A non-contrast-enhanced helical computed tomography (CT) scan is used to provide a conclusive diagnosis. Newborns, the elderly, and people who have had recent GI surgery are at risk for bowel obstruction (Dains et al., 2016). Intestinal obstruction can be caused by adhesions in the abdomen that form after surgery, an irritated intestine (Crohn's disease), diverticulitis, hernias, and colon cancer, according to Mayo Clinic (2018). The patient frequently complains of crampy pain that comes on suddenly. Vomiting is more likely to occur early in a small intestinal obstruction and later in significant bowel obstruction. A complete obstruction causes obstruction, although a partial obstruction might cause diarrhea (Dains, et al., 2016). A minor bowel obstruction might cause hyperactive, high-pitched bowel sounds. In a lower obstruction, a mass may be felt. Abdominal distention is a possibility. Abdominal x-rays, CT scans, and MRIs are used to get a definitive diagnosis.
Irritable bowel syndrome (IBS), also known as spastic colon, is a prevalent condition marked by stomach cramps, discomfort, bloating, constipation, and diarrhea (Mayo Clinic, 2017). A proper gut examination will be performed on the patient with IBS, and the stool will be blood-free. A proctosigmoidoscopy or barium enema (BE) should be considered if the patient's symptoms do not improve after 6 to 8 weeks of therapy, if the stool is positive for blood, if the patient has a family history of colorectal cancer or polyps, or if the patient's symptoms do not improve after 6 to 8 weeks of therapy (Dains, et al.).
References
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Mayo Clinic. (2018). Intestinal obstruction. Retrieved from
https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms- causes/syc-20351460
Mayo Clinic. (2017). Spastic colon: What does it mean?. Retrieved from
