Download Abdominal Pain Assessment: A 65-Year-Old Male Patient and more Assignments Nursing in PDF only on Docsity! lOMoARcPSD|3013804 lOMoARcPSD|3013804 NURS 6512C ABDOMINAL ASSESSMENT Subjective: 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 him 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 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: Abdominal Aortic Aneurysm (AAA) Perforated Ulcer Pancreatitis Analyze the subjective portion of the note. List additional information that should be included in the documentation. Pain rating: 8/10 Aggravating and alleviating factors: aggravated by movement, nothing has alleviated the pain Character of pain: sudden and sharp lOMoARcPSD|3013804 Decreased food intake Relationship to internal and external stressors recently lost his job Recent stool characteristics: pale yellow stool Analyze the objective portion of the note. List additional information that should be included in the documentation. Ill presenting patient with pale appearance Abdominal distension Is the assessment supported by the subjective and objective information? Why or why not? Yes, it is supported by the subjective and objective data because it analyses the patient’s symptoms of epigastric pain radiating to the back and nausea after a meal and establishes 3 possible differential diagnosis. Data from the focused assessment enables the provider to collect objective data and also draw conclusions on possible diagnosis. The assessment also takes into consideration important diagnostic tests needed. The chosen differential diagnoses all have similar presenting symptoms and will need further workup to decide on a primary diagnosis. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? CBC: To detect if the patient has a possible infection Liver enzyme test: To determine if liver is functioning well Urinalysis: To check for blood or bacteria in the urine Amylase and lipase levels: Blood work done to determine if there is a possible pancreatic infection Abdominal X-ray: Useful to help the clinician have a general view of the GI tract and in diagnosing free air. Abdominal ultrasound: can assist in evaluating the cause of stomach pain by showing clear images of soft tissue that may not be visible on Xray. If symptoms indicate a possible AAA, then an ultrasound is indicated for further studies CTA: to check for free gas in the abdomen, as this can indication perforated ulcer 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. I would reject the diagnosis of AAA at onset until further testing is done. This patient’s vital signs are stable and although he complains of intermittent pain, he does not describe his pain as tearing or ripping chest pain which is a classic presentation of patients diagnosed with AAA. (Hafeez et al., 2018) I accept Acute pancreatitis as the primary diagnosis. According to Hafeez et al., (2018), a diagnosis of acute pancreatitis can be done initially without imaging and with a presentation of abdominal pain in addition to elevated lipase or amylase can confirm this diagnosis. To add, the patient has an identifiable cause such as alcohol use and hyperlipidemia (Grigorian et al., 2019).
