Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen
Learning Resources
Required Readings (click to expand/reduce)
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.
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- 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.
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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.
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 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.
Assignment 1: Lab Assignment: Assessing the Abdomen
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. Just add in what you want to this case to make it unique to you. Do not use NA or normal.
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: ?
Assessment:
- Left lower quadrant pain
- Gastroenteritis
PLAN: This section is not required for the assignments in this course (NURS 6512)
To Prepare
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
- With regard to the Episodic note case study provided:
- Review this week’s Learning Resources, and consider the insights they provide about the case study.
- Consider what history would be necessary to collect from the patient in the case study.
- 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?
- Identify at least fivepossible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
- Analyze the subjective portion of the note. List additional information that should be included in the documentation.
- Analyze the objective portion of the note. List additional information that should be included in the documentation.
- Is the assessment supported by the subjective and objective information? Why or why not?
- What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
- 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.
Write up tips>>>>
Every patient has an interesting story to tell. The most successful write-ups are those that tell the story rather than report a list of facts.
- Be specific and descriptive with your language.
- Follow a logical chronology
- Avoid using unconfirmed diagnoses in the HPI
- Report physical examination findings (not diagnoses which belong in the assessment)
- Abbreviations are permissible as long as they are not ambiguous and are of standard acceptance.
The Chief Concern (This is the “title” of your story.)
There are different styles, choose what works best for you (or what your preceptor prefers.)
- For the purist, this is the patient’s own words in quotations.
- Common modification to “purist” approach provides the basic patient demographics, the patient’s own words (possibly edited a bit) and the duration. (e.g. 46 yo m w/ “a stabbing pain in my back” for 2 days)
- For the patient unsure why they are here or can’t communicate- CC is the physician’s reason for admission. (e.g. “Mr. Jones is referred for admission by his nephrologist for treatment of acute kidney transplant rejection.”)
- Another acceptable format: Mr./Ms. (nameof patient) is a (age)- year-old (gender, occupation), who presents to the clinic today OR is admitted to the hospital for the ___th time with a chief concern of “(symptom, not a sign or diagnosis)” of ___ duration.
DO NOT list a patient’s PMH before giving the chief complaint
- Does not allow the reader to “select a program” in which to organize their thoughts.
- If some PMH is relevant to the HPI, it can be introduced into the story when it is relevant rather than upfront.
BAD EXAMPLE: “Mr. Jones is a 53 year-old man with a history of COPD, HTN, DM, arthritis, tobacco abuse, GERD, hyperlipidemia, and pneumonia who is admitted with a chief complaint of “worsening leg pain” for the past 4 days.”
Comment on the source of the information and its reliability (in the CC or HPI ), if it is not obvious.
Do not cover up lazy interviewing by labeling the patient “poor historian”. The label “poor historian” is a red flag for a poor interviewer. If the patient truly is a poor historian, you should provide a brief explanation of why (e.g. history limited by patient’s poor attention span).
The History of Present Illness (This is the story.)
The HPI should be a chronological history of the chief concern.
- Organized in relation to the date of admission (4 days PTA…) or first onset of relevant symptoms (In 1996…).
- NEVER begins with a list of PMH
- Be specific when describing symptoms,
- Use the patient’s own words whenever possible and quantify whenever possible. (‘Mr. J could walk a mile one month ago without getting SOB, but over the past month his DOE gradually progressed to the point that he cannot walk 50 feet without stopping to catch his breath.’)
- Information obtained from a chart review, outside records, or a referring physician should fit into the HPI.
- It is acceptable to refer to confirmed diagnoses made by other physicians in your HPI.
- Information relevant to the CC obtained from a chart review, outside records, or a referring physician belongs in the HPI.
- It is acceptable to refer to diagnoses made by other physicians in your HPI. However, reserve your diagnostic impression to the ‘assessment’ portion of the write-up. (Just because a “doctor” gave a diagnosis, don’t assume it is correct. Keep your mind open.)
GOOD EXAMPLE: ‘Mr. J could walk a mile one month ago without getting dyspneic, but over the past month his DOE gradually progressed to the point that he cannot walk 50 feet without stopping to catch his breath.’
Pertinent positives and negatives (i.e. symptoms relevant to your differential diagnosis)
- Can be included in a separate paragraph after the description and elaboration of the symptoms.
- Most pertinent positives easily fit into a well-organized narrative and do not need to be listed separately.
- Pertinent negatives are factors that, if present, would have suggested a different diagnosis.
- Symptoms included in the HPI do not need to be listed again in ROS
HPI does not include a section called “ED course”
- If the patient reports something tried in the ED affected their symptoms, then that is history included in the HPI.
- If an unexpected finding in the ED is the reason for admission then you can mention that in the HPI.
- Lab, imaging, and other objectivedata belong in that section of the write-up.
Finally, you should ask how this current problem is affecting the patient’s life and any specific concerns the patient may have (i.e. a patient with chest pain may have recently had a friend die of a heart attack) and record it if relevant.
SDH Opportunity- Financial concerns frequently come up when asking how the illness is affecting the patient’s life. Are you concerned about losing your job? Are you concerned about how you will pay for your medical care?
The Past Medical History (PMH)*
- Past disease and illness, not symptoms.
- Typically documented as a numbered list.
- Include major diseases (conditions followed by a doctor), OB/GYN hx (LMP, pregnancies, childbirth experiences), hospitalizations, and operations.
- Some medical conditions should have further details provided. (For example, for patients with CHF, it is very helpful to know when that had their last ECHO and what it showed.)
Medications
- Traditionally listed after PMH because easiest to see how the diagnoses and medications relate (patients often forget diagnoses until you ask the reason for a medication)
- List dosages (if unknown, note that)
- Include OTC and supplements
- Electronically imported medication lists should ALWAYS be edited with all supplies and other non-medications removed
SDH Opportunity- Do you have concerns about being able to afford your medications?
Allergies
- Brief description of the reaction. (Nausea is not an allergy; it is an ‘intolerance’ or an ‘adverse reaction’ and should be listed as such.)
Preventive Health History*
- Usually not part of inpatient note.
- Most preventive health issues that are pertinent would be included in the HPI (e.g. in a patient with weight loss, you would definitely want to include their cancer screening history…but in the HPI).
- Immunizations are the one area that should always be addressed, particularly the pneumococcal and flu vaccines in the elderly and immunocompromised. (Pneumonia & flu are still one of the 10 leading causes of death in our country!)
The Family History (FHx)*
- First -degree relatives is the minimum.
- Routinely ask about common conditions with a genetic component (e.g. CAD, HTN, breast cancer, colon cancer, diabetes, prostate cancer, high cholesterol, depression, alcoholism).
The Social History (SHx)*
A thoughtful social history demonstrates the curiosity and humanism present in “master clinicians”.
Most relevant to inpatient:
- Marital/relationship status
- Living situation- do they have stable housing, who lives at home (including pets), and do they feel safe?
- Social supports- who could help them with ADLs, IADLs if needed, do they need help with transportation?
- Education level, English first language
- Occupation(s)
- Habits (tobacco, alcohol, drugs- include amounts)
- Diet- including food insecurity
- Activity- including mobility limitations and fall risk
We strongly encourage learning about your patient’s daily activities, hobbies, and interests. (If you do this consistently, one day this information will give you a key insight into a patient’s diagnosis. Also, it shows you care and will build trust.)
SDH Opportunity- A good SHX addresses SDH, which is very relevant to planning a successful transition out of the hospital. Concerns raised in the SHX can be elaborated with formal screening tools.
*Effective Documentation in the EMR: Avoiding “Note Bloat”
The EMR has separate sections for all historical data except the HPI and ROS. For patients who already have those sections populated with data, it is efficient to update (and correct) this data rather than repeat it all in the note. In your note you can include only what is relevant to the current admission (or visit in an outpatient setting). (Some faculty will not like this but the advantage is you don’t paste in a lot of extraneous details (creating “note bloat”) like the tonsillectomy at age 3 and mother with osteoarthiritis, and even preventive health maintenance which is important overall but rarely during an acute hospitalization.)
For example, you could write the following,
“We reviewed and updated the complete past, family and social history in the EMR and details can be viewed there.
Past history is notable for 1. HTN 2. poorly controlled diabetes 3. chronic kidney disease with last GFR 44 5/2011.
Family history- see EMR
Social history- he still lives alone with few supports and continues to smoke”
This requires a much higher skill level than just dumping everything in the note. Are you up to the challenge?
The Review of Symptoms/Systems (ROS)
- Organized by organ system but is really a catalogue of symptoms.
- You do not need to list all the negatives (all pertinent negatives would be in the HPI already).
- List all positives (not already covered in HPI).
- Potentially serious positive findings require elaboration. (E.g. patient with cough during the ROS mentions black, tarry stools, you shouldn’t merely list “black, tarry stools”. You need to elaborate on this (perform a mini-HPI).
- Do not repeat information you already included in the HPI or PMH here as it is redundant.
A Sample Of This Assignment Written By One Of Our Top-rated Writers
Abdominal Pain
The SOAP note gives the case of a 47-year-old male who presented with stomach pain and diarrhea that began three days ago. The patient’s abdomen is soft on physical exam and has hyperactive bowel sounds (BS) and LLQ tenderness. The purpose of this assignment is to examine the SOAP note and identify the needed additional information and discuss likely diagnoses.
Subjective Portion
The HPI should have described the abdominal pain, including duration, timing, characteristics, exacerbating, and alleviating factors. In addition, it should provide information describing diarrhea, including the onset, timing, frequency, and characteristics, such as if it is bloody, watery, mucoid, or malodorous. The subjective part should also have the patient’s surgical history and immunization status. Besides, the social history should have provided additional information like the patient’s occupation, education level, hobbies, and health promotion practices. Lastly, a review of systems (ROS) is missing, including the pertinent positives and negatives not provided in the HPI.
Objective Portion
The objective section should have the patient’s general assessment, which includes hygiene, appearance, alertness level, facial expressions, body language, speech, and attitude. A focused abdomen exam should include comprehensive findings from the abdominal exam. Thus, it should have provided findings from inspection like the abdomen’s pigmentation, symmetry, contour, scars, and visible masses or peristalsis. In addition, findings from abdominal percussion and palpation should be provided, like the liver span, spleen position, presence of masses, organomegaly, guarding, or rebound tenderness.
Assessment Portion
LLQ pain is backed by the physical exam finding of tenderness in the LLQ but does not align with the patient’s symptom of generalized abdominal pain. Gastroenteritis (GE) is supported by subjective and objective findings, including generalized abdominal pain, diarrhea, nausea, and hyperactive BS.
Diagnostic Tests
Diagnostic tests suitable for this client Complete blood count (CBC) and stool culture test. CBC will be used to identify the white blood cell count, establishing the presence and cause of infection (Geyer, 2020). The stool test will establish the presence of blood, bacteria, viruses, or parasites in the stool, which will help determine the cause of the GI symptoms.
Diagnosis
GE is an acceptable diagnosis due to pertinent symptoms of abdominal pain, diarrhea, hyperactive BS, mild fever (99.8 F), and abdominal tenderness of palpation. On the other hand, I would disregard LLQ pain as a diagnosis since it is a physical exam finding indicating an underlying disorder.
The probable diagnoses for this case are:
Acute Diarrhea: Acute diarrhea is characterized by an abrupt onset of three or more loose or watery stools per day. Patients may present with dehydration, nonspecific abdominal cramping or pain, flatulence, increased BS, abdominal tenderness worsened by palpation, and perianal erythema (Drancourt, 2018). Acute diarrhea is a likely diagnosis based on the patient’s diarrhea, generalized abdominal pain, and abdominal tenderness on palpation.
Gastroenteritis: GE occurs due to inflammation of the stomach lining. It is associated with vomiting, anorexia, nausea, diarrhea, abdominal pain/tenderness, and hyperactive BS (Bányai et al., 2018). Findings of abdominal pain, diarrhea, nausea after meals, and hyperactive BS make GE a possible diagnosis.
Colonic Diverticulitis: Patients with colonic diverticulitis have LLQ abdominal pain and tenderness, a palpable sigmoid, nausea, vomiting, fever, rebound, and guarding (Tursi et al., 2020). Thus, it is a likely diagnosis owing to the patient’s mild fever, nausea, and LLQ pain.
Conclusion
The subjective part should have additional information describing the abdominal pain and diarrhea. Physical findings from the general assessment and detailed abdominal exam should have been provided. Possible diagnoses include acute diarrhea, GE, and colonic diverticulitis.
References
Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175-186. https://doi.org/10.1016/S0140-6736(18)31128-0
Drancourt, M. (2018). Acute Diarrhea. Infectious Diseases, 335–340.e2. https://doi.org/10.1016/B978-0-7020-6285-8.00038-1
Geyer, B. (2020). Diagnosis and management of acute gastroenteritis in the emergency department. Emergency medicine practice, 22(3), 1–24.
Tursi, A., Scarpignato, C., Strate, L. L., Lanas, A., Kruis, W., Lahat, A., & Danese, S. (2020). Colonic diverticular disease. Nature reviews. Disease primers, 6(1), 20. https://doi.org/10.1038/s41572-020-0153-5
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