A male went to the emergency room for severe midepigastric abdominal pain.
A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.
Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.
In this Lab Assignment, 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.
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:
o Review this week’s Learning Resources, and consider the insights they provide about the case study.
o Consider what history would be necessary to collect from the patient in the case study.
o 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?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. 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.
Sample Solution
The patient in the episodic note case study is a male who has come to the emergency room with severe mid-epigastric abdominal pain. In order to formulate an accurate diagnosis for this patient, it would be important to first review both the subjective and objective portions of the documentation.
In terms of subjective notes, it is important to gather information about the patient’s medical history as well as any prior symptoms that may have led up to their current condition. Questions should be asked regarding what type of medications they are currently taking, if they have ever had similar episodes before and if so what action was taken at that time (Arnetz et al., 2021). Additionally, details such as when exactly did their pain begin and how long has it been going on for should also be documented which can help provide further insight into potential causes (Gardner & Barletta 2018).
On the other hand, data from physical exams and diagnostic tests need to be collected in order obtain more concrete evidence about the source of the problem. Examples here could include bloodwork or imaging studies such as CT scans which can help detect any abnormalities such organ enlargement or growths (Arnetz et al., 2021). Furthermore, these results could then used make a differential diagnosis which includes conditions such pancreatitis, cholecystitis , appendicitis etc depending on what specific findings reveal (Gardner & Barletta 2018).
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