Nurs 6512 head to toe assessment

Advanced Health Assessment

NURS 6512: Advanced Health Assessment

Sample Paper

Abdominal Soap Case Study

Patient Information:

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

S.

SUBJECTIVE:

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

HPI: JR is a 47-year old Caucasian male who presents to the clinic today with generalized abdominal pain that started three days ago. He reports having some nausea after eating. He rates his pain scale at 5/10 today, but pain scale had been severe as high as 9/10 when it begins first, and he denies taking any medication.

Location: In the abdomen. The specific location of the pain is unknown.

Onset: Three days ago

Character: Unknown

Associated signs and symptoms: GI bleeds four years ago, stomach pain, diarrhea, and nausea.

Timing: Nausea after eating

Exacerbating/ relieving factors: Unknown

Severity: Pain scale is 9/10.

Current Medications: Lisinopril 10mg, Amlodipine 5mg, Metformin 1000mg,

Lantus 10units qhs.

Allergies: NKDA

PMHx: HTN, Diabetes, GI bleed for four years ago. The patient is up to date with all immunizations and last tetanus vaccine was 5yrs ago

Social History: Denies tobacco use, occasional alcohol use and is married with three children (1girl, and two boys)

Family History: Pt has no history of colon cancer. Father has a history of Diabetes mellitus type 2 and HTN; mother has a history of HTN, Hyperlipidemia, and GERD.

O.

OBJECTIVE:

Physical exam:

VSS: Temp 99.8, BP 160/86, R 16, P 92, Height 5'10", Weight 248lbs, BMI

35.6.

CV: Patient denies chest pain and palpitations: regular heart rate, and regular rhythm. No murmurs.

LUNGS: Lungs clear during auscultation, and chest wall symmetrical

SKIN: Skin intact dry and warm, no lesions, no urticaria

ABD: Abdomen is soft; bowel sounds is hyperactive, had pain in the left lower quadrant (LLQ)

Diagnostic: None

Analyzing Additional subjective information needed

Based on the scenario given in the history of present illness (HPI), the patient verbalized having generalized abdominal pain but failed to specify the location of the pain. The patient unable to states the character and nature of the pain such as aching, stabbing, colicky, dull, or gnawing. Also, in the relieving factor patient fails to mention any pain relieving therapy used to alleviate the pain such as heat or cold treatment, change of position, medication, and or distraction. The patient did not state exacerbation factors for the abdominal pain, such as a change in position, time of day, input of foods, or anything else that makes the pain worst. Also, the patient was unable to mention the timing of the pain, whether abdominal pain is constant or intermittent. The bowel movements frequency, color, and consistency should include in history. When the patient started using alcohol, but do not specify the alcohol type, amount, and rate of consumption, which is essential information that needs to add in social history. The medication verbalized are lacking information on how many times in a day patient takes the following medications such as Lisinopril 10mg, Amlodipine 5mg, and Metformin 1000mg and fails to states when drugs started and the last time is taken needs to document. Information based on the patient's educational and work history should add to the social history assessment. The subjective evaluation should have added a complete review of systems (ROS) to reveal all body systems that can help to include or rule out a differential diagnosis or other symptoms that the patient may have forgotten or deemed unimportant to further aid in finding a diagnosis. The ROS is an inventory of specific body systems designed to document any symptoms the patient may be having or had in the past (Sullivan, 2012).

Analyzing Additional objective information needed

To ensure correct diagnosis, an advanced practice nurse (APN) must perform and document a complete head to toe assessment. Physical examination of all the body systems of the patient is necessary and must do for every patient that visits the clinic or hospital with a chief complaint (CC) requesting for health care. Other assessments are given necessary to retrieve to ensure adequate objective information or correct diagnosis are vital signs, heart, lungs, skin, and abdominal, then the APN must complete the other necessary body systems. Skin color was omitted and should be added to check the presence of jaundice. Also, the temperature Celsius or Fahrenheit should include. Also, abdominal assessment, such as palpation to check for masses and tenderness, and percussion should consist of in the objective assessment. Percussion is used to check the size of the organs and to evaluate fluid presence. Palpation could show an enlargement of the liver organ, and kidneys and percussion can help in assessing an ascites. An assessment of the groin is essential to rule out an inguinal hernia and testicular torsion.

Is this Assessment Supported by the Subjective and Objective Assessment?

Based on the above two analysis, the diagnosis of gastroenteritis cannot support the information obtained from the objective and subjective assessment. The subjective assessment has slim and incomplete information to get the full picture. The objective evaluation is incomplete and requires the assessment of the other body systems to rule out other diagnoses and support the diagnosis of gastroenteritis. No information is given on performing any diagnostic testing to rule out or further to confirm the gastroenteritis. The information in the objective section is not enough to make a proper diagnosis. The diagnostic exams not conducted, and that makes the objective part of the note incomplete.

Appropriate Diagnostic Tests

In every patient assessment, it is necessary to perform appropriate diagnostic tests when necessary, to help the APN to ensure the correct diagnosis. With the above scenario lacking many information diagnostic testing should be necessary such as a guaiac fecal occult blood test. A guaiac fecal occult blood test must be collected to rule out the presence of blood in the stool due to his history of GI bleeding four years ago (National Cancer Institute, 2018). Also, based on the scenario, the patient complains of diarrhea, then a stool testing and culture are required to assess the presence of Clostridium difficile (C-Diff), norovirus and rotavirus which are often the primary cause of gastroenteritis (Mayo Clinic, 2018). An abdominal CT (computed tomography) is required and valuable in identifying abdominal organs, tumors, lesions, injuries, intra-abdominal bleeding, infections, unexplained abdominal pain, obstructions or other conditions (John Hopkins Medicine, n.d.). Based on the case study, the patient's symptom for diarrhea requires more tests like a complete metabolic panel (CMP) to assess patient's electrolytes and plan treatment when necessary.

Reject or Accept Diagnosis?

Gastroenteritis is the inflammation and irritation of the stomach and intestines caused by a bacterial or viral infection (Dains et al., 2016). This health issue usually characterized by hyperactive bowel sounds, diffused, and cramping abdominal pain, fever, diarrhea, nausea, and vomiting (Dains et al., 2016). During the patient's assessment, patient hyperactive bowel sounds, diarrhea, and nausea noted, but the pain localized to left lower quadrant (LLQ), with no fever and vomiting. Based on my assessment on this scenario, the writer has identified three differential diagnoses of renal calculi, irritable bowel syndrome (IBS) and intestinal obstruction as the possible causes of patient J.R. abdominal pain, diarrhea, and nausea.

Renal calculi are the development of stones that are made of calcium salts, uric acid, cysteine, and struvite in the pelvis of the kidney (Ball et al., 2015). Symptoms of renal calculi flank pain that worsens as the stone pass through ureters, nausea, vomiting, and hematuria and dysuria (Ball et al., 2015). Performing a urinalysis may show hematuria, PH testing of the urine can determine the presence of crystals, and along with a CT scan to identify the stones.

Irritable bowel syndrome (IBS) is prevalent and affects the large intestine. Symptoms of the disease may include abdominal pain characterized by cramping or bloating relieved when passing a bowel movement, excess gas, diarrhea or constipation, and mucus in the stool (Mayo Clinic, 2018). There is no specific test to diagnose IBS, but the health care provider can base it off a complete medical history, physical exam, and another testing to rule out other conditions (Mayo Clinic, 2018).

Intestinal obstruction is a blockage in your intestines occluding food, gas, and stool to pass freely (John Hopkins Medicine, 2018). The cause for the obstruction can be adhesions, hernia, scarring, tumors, inflammatory bowel disease, diverticulitis, or a foreign object (John Hopkins Medicine, n.d.). Patients' symptoms can include severe abdominal pain, nausea, vomiting, hyperactive bowel sounds in certain areas, feeling of fullness, diarrhea, or constipation (John Hopkins Medicine, n.d.). CT, X-ray or MRI exam can be performed to identify obstruction as well as physical exam and complete health history (John Hopkins Medicine, n.d.).

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.

John Hopkins, Medicine. (n.d.). Abdominal CT Scans: What You Need to Know. Retrieved from https://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/ct_scan_of_the_abdomen_92,p07690

John Hopkins, Medicine. (n.d.). Understanding an Intestinal Obstruction | Johns Hopkins Medicine Health Library. Retrieved from https://www.hopkinsmedicine.org/healthlibrary/conditions/adult/digestive_disorders/understanding_an_intestinal_obstruction_134,199

Mayo Clinic. (2019, March 17). Irritable bowel syndrome - Diagnosis and treatment - Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/diagnosis-treatment/drc-20360064

Sullivan, D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis.