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ASSESSING THE ABDOMEN

Published by admin at January 3, 2023
Categories
  • Nursing
Tags
  • Assessing the Abdomen

 

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 five possible conditions that may be considered in a differential diagnosis for the patient. 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. Assignment1 Abdominal Case 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 days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s 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 his 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

 

 

 

 

Sample Solution

To collect additional history from the patient and gain more information about their condition, a comprehensive assessment of the patient’s presenting symptoms must be conducted. The clinician should obtain a detailed description of the abdominal pain, including its quality (e.g., sharp, dull), location (e.g., epigastric or radiating to back), duration, and any associated symptoms such as nausea and vomiting. Additionally, questions regarding recent changes in diet or activity levels should be asked in order to rule out causes related to lifestyle choices prior to evaluating other possible causes for abdominal pain. Furthermore, it is important to ask about family history involving AAA or pancreatitis considering this information may yield greater insight into underlying conditions that could contribute to abdominal pain.

Physical exams are an important part of diagnosing patients with abdominal pain; they provide clinicians with information necessary for further evaluation and can assist in narrowing down potential diagnoses. During physical exams, clinicians should evaluate the patient’s vital signs – temperature, blood pressure and heart rate – as well as their general appearance (i.e., color). Clinicians should also inspect the abdomen for tenderness or masses which may indicate perforated ulcer or AAA respectively; additionally palpation for areas of tenderness would also help determine if there are any localized sites associated with the patient’s abdominal discomfort indicating inflammation from pancreatitis which could occur alongside AAA formation or perforation due to ulcer formation . A thorough neurological exam will also be performed since lower abdomen conditions can affect nerve pathways leading up towards brain structures responsible for sensation perception including those located within limbic regions like amygdala/hippocampal complex & insula/thalamus system which then link directly brain stem nucleii involved in autonomic responses such as HR & BP regulation through sympathetic-parasympathetic pathways .

Diagnostic tests provide essential information that can help clinicians make accurate diagnoses when assessing patients with abdominal pain; these tests allow healthcare professionals to visualize internal organs thereby determining if pathology exists without having to perform invasive procedures such as exploratory surgeries . Commonly used diagnostic imaging techniques include ultrasounds (US) also known as sonography scans , computed tomography angiograms (CTA) , magnetic resonance imaging scans (MRI) & positron emission tomography scans (PET) which all use different frequencies & radiation types in order capture images inside body cavities/organs being studied on monitor screens helping physicians detect disorders by comparing normal anatomical features against actual ones found during scan process thus allowing them diagnose most cases accurately even before final result reports received due confirmatory testing have completed .

The results of both physical exams and diagnostic tests will be used together by medical professionals when making a diagnosis; physical examinations generally yield subjective results while diagnostic test results provide objective measurement values that can be compared against established norms depending upon specific disorder suspected given particular case presentation environment being evaluated at time initial assessment occurred therefore helping doctors arrive at most probable cause based off combined data sets obtained throughout course investigation into purposeful resolution end goal desired outcome achieved optimal level care provided each individual patient situation.

understudies. Given the expected worth of such figures propelling scholastic achievement and hence impacting results like maintenance, wearing down, and graduation rates, research is justified as it might give understanding into non-mental techniques that could be of possible benefit to this populace (Lamm, 2000) . Part I: INTRODUCTION TO THE STUDY Introduction The country is encountering a basic lack of medical care suppliers, a deficiency that is supposed to increment in the following five years, similarly as the biggest populace in our country’s set of experiences arrives at the age when expanded clinical consideration is essential (Pike, 2002). Staffing of emergency clinics, centers, and nursing homes is more basic than any time in recent memory as the enormous quantities of ‘people born after WW2’s start to understand the requirement for more continuous clinical mediation and long haul care. Interest in turning into a medical caretaker has disappeared as of late, presumably because of the historical bac

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