Wk6AssessmAssgn

Patient Information:

Initials: JR Age: 47 Sex: Male Race: Caucasian

SUBJECTIVE.

CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”

HPI: JR, 47-year-old white male, 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.

Current Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units at bedtime

Allergies: NKDA

PMHx: HTN, Diabetes, hx of GI bleed 4 years ago Soc Hx: Denies tobacco use; occasional beer, married, 3 children (1 girl, 2 boys)

Fam Hx: No hx of colon cancer, Father hx DM type 2, HTN, Mother hx HTN, Hyperlipidemia, GERD

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, positive pain in the LLQ on palpation

Diagnostics: None

ASSESSMENT .

Differential Diagnoses: Left lower quadrant pain, Gastroenteritis

Is the Current Diagnosis Supported by the Current Information?

Gastroenteritis cannot be supported by current information; additional subjective and objective information is needed to complete a thorough assessment. In addition, diagnostic testing is needed to rule out any other possible diagnoses.

Additional Subjective Information Needed

The patient is very vague about his abdominal pain. The practitioner must ask more detained question to identify the location and description of his abdominal pain. Is the pain sharp, cramping, aching, shooting, stabbing or throbbing? What was the patient doing when the pain started? What aggravates the abdominal pain or cause it to flare up? How long does the pain last when it starts? Is there anything that makes your abdominal pain better? Do you have any problems urinating? Not only does the provider need more information from the patient about the chief complaint, there must be a subjective review of systems (ROS) to complete a proper examination. The subjective ROS would be as follows:

Subjective Review of Systems:

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  Abdominal pain with nausea. Denies any vomiting. States he has had a lot of diarrhea.

GENITOURINARY:  Denies any urinary issues.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

Additional Objective Information Needed

In order to complete a thorough assessment regarding an abdominal complaint, the advanced practice nurse must review many different systems in addition to what has already been assessed. The practitioner must examine the patient’s groin area to rule out an incarcerated hernia or testicular torsion (Dains, et al, 2016). Percussion of the flank area can rule out renal calculi. Sexually transmitted infections (STIs) and prostatitis can be ruled out via a genital exam. The practitioner must also look for frank blood or fecal occult blood to rule out neoplasm. Because abdominal pain can be referred from other areas, the provider should also examine the lungs, heart, head and neck, and musculoskeletal system (Dains, et al, 2016).

Is the Current Diagnosis Acceptable?

The current diagnosis is unacceptable without further assessment and testing.Although, gastroenteritis can be diagnosed via subjective and objective assessment data only (Dains, Bauman, Scheibel, 2015), the practitioner must rule out all possible diagnosis. Usually patients with gastroenteritis have a diffuse, cramps, abdominal pain accompanied by nausea, vomiting, diarrhea, and fever. The patient is afebrile with nausea without vomiting and diarrhea. According to Dains, et al, the patient with gastroenteritis will have hyperactive bowel sounds, which is present. Gastroenteritis usually resolves without any treatment and requires no diagnostic testing.

Conditions That May Be Considered as a Differential Diagnosis

The patient could be experiencing several abdominal issues. The patient has complained of diffuse abdominal pain with nausea and has hyperactive bowel sounds. These vague symptoms can also point to ureterolithiasis, bowel obstruction, or irritable bowel syndrome (IBS). Each condition requires specific diagnostic testing in order to form an accurate diagnosis.

1. Ureterolithiasis occurs when kidney stones form in the kidney and begins to travel through the ureter to the bladder then the urethra. The patient reports the sudden onset of excruciating intermittent colicky pain that can progress to a constant pain (Dains, et al, 2016). The pain is in the lower abdomen and flank and radiates to the groin. The patient with ureterolithiasis may also have nausea, vomiting, abdominal distention, chills, hematuria, and fever (Dains, et al, 2016). A urinalysis can be done to determine urine pH and the presence of crystals can help identify stone composition. A definitive diagnosis is made via non-contrast- computed tomography (CT) scan.

1. Bowel obstruction occurs in newborns, the elderly, and those with recent GI surgery and those with unknown neoplasm (Dains, et al, 2016). Causes of intestinal obstruction may include adhesions in the abdomen that form after surgery, an inflamed intestine (Crohn's disease), diverticulitis, hernias, and colon cancer (Dains, et al, 2016). Patients commonly present with sudden onset of cramp pain with increasing intensity and nausea with or without vomiting (Dains, et al, 2016). Most commonly occurs early within the small intestinal obstruction and late with large bowel obstruction (Dains, et al, 2016). Obstipation occurs with a complete obstruction, but diarrhea can be present with a partial obstruction (Dains, et al, 2016). Hyperactive, high-pitched bowel sounds can be present with a small bowel obstruction while a mass may be palpable in a lower obstruction. Abdominal distention can be present with both small or large bowel obstructions(Dains, et al, 2016) . Definitive diagnosis is made with abdominal x-rays, CT scan, or MRI.

1. Irritable bowel syndrome (IBS)- is a common disorder that is characterized by abdominal cramping, abdominal pain or discomfort, bloating, and altered bowel habits, consisting of diarrhea or constipation or alternating between diarrhea and constipation (Hurd, et al., 2013). The patient with IBS will have a normal bowel examination and the stool will be negative for blood. If the onset of IBS is at middle age or older, if the stool is positive for blood, if there is a family history of colorectal cancer or polyps, or if the patient fails to show improvement of symptoms after 6 to 8 weeks of therapy a proctosigmoidoscopy or barium enema (BE) should be considered (Dains, et al).

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

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.

Hurd, M., Schwartz, M. E. . M. D. . M. A. . P. D., & Ó, M. C. A. . M. A. . M. D. . M. S. . D. S. (2013). Irritable bowel syndrome (IBS). Magill’s Medical Guide (Online Edition). Retrieved from Walden Library Database