Assessment Of The Abdomen And Gastrointestinal examples

Assessment Of The Abdomen And Gastrointestinal example

Subjective Portion

LZ is a 65years old male presenting at the emergency department with abdominal pain in the epigastric region. It is of sudden onset, intermittent, and radiates to the back. Meals are the aggravating factor and have no relief even after taking PPI. pain has been increasing in severity and causes vomiting. The patient denies fever, diarrhea, and other abdominal symptoms. The patient is hypertensive and takes metoprolol 50mg. she has no known history of food and drug allergy. She has a positive family history of GERD, hypertension, and hyperlipidemia. He divorced five years ago and has two children. He has a positive history of ETOH and smoking for 20years. This subjective information illustrates that the patient has an illness affecting the gastrointestinal system. From the patient, I would ask if the character of the pain is like a stabbing, sharp, and burning sensation. For example, peptic ulcer disease presents with acute onset epigastric pain, of burning nature, radiating to the back, aggravated by meals, and relieved by rest (Kamada, et al, 2021). I would ask if the patient experiences other symptoms like nausea, heartburn, reflux, and abdominal fullness. I would ask about the vomitus content, color, and bloodstains to rule out hematemesis in acute upper gastrointestinal bleeding. The color and consistency of help determine the illness because gastric or duodenal ulcers present with black tarry stool and constipation. Enquire about the over-counter medication for random pain because NSAIDs like aspirin and ibuprofen trigger epigastric pain. Ask about the general symptoms like fatigue, night sweats, chills and rigors, and weight loss because H.pylori-induced peptic ulcer disease presents with low-grade fever, chills and rigors, and fatigue. About ETOH and smoking, I would ask the type of alcohol, the amount, percentage, and frequency because spirits and whisky corrode the abdomen more compared to beers. Assessment Of The Abdomen And Gastrointestinal examples

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Objective Data

The patient’s vitals are Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs. the heart has a regular rate and rhythm with no murmurs. The chest wall is symmetrical. The skin is intact without lesions and urticarial. The abdomen is tender in the epigastric area with guarding but without mass or rebound. In the objective data, I would do the patient’s general examination. Is the patient alert, oriented, or in pain? is there pallor jaundice, dehydration, lymphadenopathy, and edema? This is because most abdominal diseases with epigastric pain may also have jaundice due to the obstruction of the gall bladder, dehydration due to vomiting, and pallor due to bleeding. Additionally, the mental state examination is important because a patient with acute pancreatitis may present with confusion.  For the abdominal examination, I would include the contour/fullness, percussion note, bowel sounds, liver span, and organ enlargement.

Diagnostic Investigations

1. Endoscopic or invasive Pylori testing
2. Endoscopy is highly sensitive for the diagnosis of gastric ulcers and duodenal ulcers. It also allows cytologic brushing of the gastric ulcer to differentiate from the beginning or malignant ulcer.
3. A chest radiograph is useful to detect free air in the abdomen when perforation is suspected.
4. Serum gastrin levels screen for Zollinger-Ellison syndrome in patients with multiple ulcers and a family history of ulcers.
5. Complete blood count to rule out infections and chronic blood loss
6. Amylase, lipase, and liver transaminase levels help in ruling out other causes of epigastric pain. Assessment Of The Abdomen And Gastrointestinal examples

Assessment

The patient presents with epigastric pain of acute onset radiating to the back, worse on meals, and results in vomiting. On examination, the patient has hypotension and a tender abdomen in the epigastric area with guarding but without mass or rebound. This information partially supports the assessment because the patient has no signs and symptoms of an abdominal aortic aneurysm. Instead, an abdominal aortic aneurysm presents with back, flank, abdominal, and groin pain (Yuan, et al, 2021). Other symptoms are nausea, vomiting, dysuria, polyuria, and blue toe syndrome. The patient did not present with urinary symptoms and does not have blue toe syndrome upon examination. Perforated ulcer and pancreatitis present with epigastric pain associated with meals and radiates to the back. However, pancreatitis has support from the subjective and objective data because the patient has no fever, jaundice, tachypnea, altered mental status, and tachycardia. I do not agree with the diagnosis because the patient has no similar signs and symptoms. Instead, my diagnosis is perforated peptic ulcer disease. Assessment Of The Abdomen And Gastrointestinal examples

Differential diagnosis

1. Peptic ulcer disease
2. Acute gastritis
3. Acute pancreatitis
4. Acute cholangitis
5. Cholecystitis

Peptic ulcer disease PUD is a laceration that involves the stomach and the duodenum. It can be either a gastric ulcer or a duodenal ulcer. PUD extends through the muscularis mucosa. The epithelial cells produce mucus in response to the irritation in the epithelial lining and cholinergic stimulation. This creates a good balance between gastric secretions and gastro-duodenal defense. However, factors like non-steroidal anti-inflammatory drugs, H.pylori infection, alcohol, pepsin, acid, and bile salts alter the mucosa defense by allowing back the diffusion of hydrogen ions that subsequent epithelial injury.  Additional causes of PUD are lifestyle habits like smoking tobacco, severe physiological stress, hypersecretory states, and genetics. The signs and symptoms are epigastric pain characterized by gnawing and burning sensation and occur after meals. The pain radiates to the back and results in fullness or bloating associated with nausea and emesis a few hours after food intake. Heartburn, chest discomfort, Malena stools, and symptoms of anemia (Kamada, et al, 2021) are additional symptoms. Perforated peptic ulcer disease presents with epigastric pain radiating to the back. Upon abdominal examination, the patient has generalized tenderness, rigidity, and guarding of the abdomen. Other signs are tachycardia, tachypnea, and hypotension.

Acute gastritis is the inflammation of the gastric mucosa. The inflammation of gastric mucosa can be erosive and non-erosive. Causes of the erosive gastric mucosa are NSAIDs, alcohol, stress, radiation, reflux, cocaine, and bile (Lin, et al, 2021). Causes of non-erosive gastritis are recurrent H.pylori infections. If not treated, acute gastritis may result in bleeding, gastric outlet obstruction, dehydration, and kidney injury. The presenting signs and symptoms are epigastric pain of gnawing or burning sensation, accompanied by nausea and vomiting. The pain worsens on eating. The physical examination findings show epigastric tenderness. Assessment Of The Abdomen And Gastrointestinal examples

Acute pancreatitis is the inflammation of the pancreas whereby the pancreatic enzymes autodigest the gland (Mederos, et al, 2022). It presents with a dull abdominal pain in the upper quadrant radiating to the back. Associating symptoms are nausea, vomiting, diarrhea, fever, abdominal tenderness, jaundice, dyspnea, and acute confusion. Characteristic findings of pancreatitis are erythematous skin nodules, grey-turners syndrome, and Cullen sign.

Acute cholangitis is the inflammation of the biliary tract, especially from a gallstone. Common bacterial infections are from the klebsiella, enterococcus, and pseudomonas. The biliary obstruction hosts the bacteria causing immune dysfunction. Causes of biliary obstruction are common bile duct stones, obstructive tumors, strictures or stenosis, and Ascaris lumbricoides infection. Signs and symptoms of acute cholangitis are abdominal pain in the right upper quadrant, jaundice, fever, altered mental status, and malaise. Physical examination reveals tachycardia, right upper quadrant tenderness, hypotension, hepatomegaly, jaundice, and altered mental status.

Cholecystitis is the inflammation of the gallbladder due to the obstruction of the cyst duct by the gallstones. Obstruction of the cystic duct leads to the inflammation of the gallbladder limiting the blood flow and lymphatic drainage eventually leading to ischemia and necrosis.  Risk factors for cholecystitis are old age, obesity, diabetes mellitus, major surgery, sepsis, and severe traumas. The presenting signs and symptoms are colicky epigastric pain that radiates to the right upper quadrant. Associating symptoms are nausea, vomiting, and jaundice. On examination, the patient has a palpable gall bladder, tachycardia, and tenderness at the epigastric region often with guarding or rebound. Assessment Of The Abdomen And Gastrointestinal examples

References

Kamada, T., Satoh, K., Itoh, T., Ito, M., Iwamoto, J., Okimoto, T., … & Koike, K. (2021). Evidence-based clinical practice guidelines for peptic ulcer disease 2020. Journal of gastroenterology, 56(4), 303-322.

Lin, X., Chen, H., & Lin, Y. N. (2021). The clinical efficacy and safety of atropine combined with omeprazole in the treatment of patients with acute gastritis: a systematic review and meta-analysis. Annals of palliative medicine, 10(9), 9535-9543.

Mederos, M. A., Reber, H. A., & Girgis, M. D. (2021). Acute pancreatitis: a review. Jama, 325(4), 382-390.

Yuan, Z., Lu, Y., Wei, J., Wu, J., Yang, J., & Cai, Z. (2021). Abdominal aortic aneurysm: roles of inflammatory cells. Frontiers in Immunology, 11, 3758.

NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System Week 6: Assessment of the Abdomen and Gastrointestinal System On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning? Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea. This week, you will explore how to assess the abdomen and gastrointestinal system. Learning Objectives – Week 6: Assessment of the Abdomen and Gastrointestinal System Students will: Evaluate abnormal abdomen and gastrointestinal findings Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system ASSIGNMENT 1: LAB ASSIGNMENT, ASSESSING THE ABDOMEN Week 6 – The Episodic note case study: Abdominal Assessment ABDOMINAL ASSESSMENT 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: Assessment Of The Abdomen And Gastrointestinal examples

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 PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. 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 five possible conditions that may be considered in a differential diagnosis for the patient. The Assignment (In the past some students have listed each question that needs to be answered and then wrote their narrative under each question). This is easier for some students. 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. DO NOT rewrite a SOAP note. Tell me whats wrong with the Episodic SOAP Note, by responding to the statements/questions above. Read the SOAP note for Abdominal Assessment, do this in paragraph form. Use subheadings for the 5 Statements/questions. These are from the Rubric. Rubric Detail Select Grid View or List View to change the rubric’s layout. Content Name: NURS_6512_Week_6_Assignment1_Rubric Excellent Good Fair Poor Quality of Work Submitted: The extent of which work meets the assigned criteria and work reflects graduate level critical and analytic thinking. Points Range: 27 (27%) – 30 (30%) Assignment exceeds expectations. All topics are addressed with a minimum of 75% containing exceptional breadth and depth about each of the assignment topics. Points Range: 24 (24%) – 26 (26%) Assignment meets expectations. All topics are addressed with a minimum of 50% containing good breadth and depth about each of the assignment topics.Assessment Of The Abdomen And Gastrointestinal examples  Points Range: 21 (21%) – 23 (23%) Assignment meets most of the expectations. One required topic is either not addressed or inadequately addressed. Points Range: 0 (0%)– 20 (20%) Assignment superficially meets some of the expectations. Two or more required topics are either not addressed or inadequately addressed.

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Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to:Understand and interpret the assignment’s key concepts. Points Range: 27 (27%) – 30 (30%) Demonstrates the ability to critically appraise and intellectually explore key concepts. Points Range: 24 (24%) – 26 (26%) Demonstrates a clear understanding of key concepts. Points Range: 21 (21%) – 23 (23%) Shows some degree of understanding of key concepts. Points Range: 0 (0%)– 20 (20%) Shows a lack of understanding of key concepts, deviates from topics. Assimilation and Synthesis of Ideas: The extent to which the work reflects the student’s ability to:Apply and integrate material in course resources (i.e. video, required readings, and textbook) and credible outside resources. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System Points Range: 18 (18%) – 20 (20%) Demonstrates and applies exceptional support of major points and integrates 2 or more credible outside sources, in addition to 2-3 course resources to support point of view. Points Range: 16 (16%) – 17 (17%) Integrates specific information from 1 credible outside resource and 2-3 course resources to support major points and point of view. Points Range: 14 (14%) – 15 (15%) Minimally includes and integrates specific information from 2-3 resources to support major points and point of view. Points Range: 0 (0%)– 13 (13%) Includes and integrates specific information from 0 to 1 resource to support major points and point of view. Written Expression and FormattingParagraph/Sentence Structure: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance. Points Range: 9 (9%) – 10 (10%) Assessment Of The Abdomen And Gastrointestinal examples Paragraphs/Sentences follow writing standards for structure, flow, continuity and clarity Points Range: 8 (8%)– 8 (8%) Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 80% of the time. Points Range: 7 (7%)– 7 (7%) Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity 60%- 79% of the time. Points Range: 0 (0%)– 6 (6%) Paragraphs/sentences follow writing standards for structure, flow, continuity and clarity < 60% of the time. Written Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation. Points Range: 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors. Points Range: 3 (3%)– 4 (4%) Contains a few (1-2) grammar, spelling, and punctuation errors. Points Range: 2 (2%)– 2 (2%) Contains several (3-4) grammar, spelling, and punctuation errors. Points Range: 0 (0%)– 1 (1%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Written Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed. Points Range: 5 (5%) – 5 (5%) Contains parenthetical/in-text citations and at least 3 evidenced based references are listed. Points Range: 3 (3%)– 4 (4%) Contains parenthetical/in-text citations and at least 2 evidenced based references are listed Points Range: 2 (2%)– 2 (2%) Contains parenthetical/in-text citations and at least 1 evidenced based reference is listed Points Range: 0 (0%)– 1 (1%) Contains no parenthetical/in-text citations and 0 evidenced based references listed. Assessment Of The Abdomen And Gastrointestinal examples