Abdominal Assessment In This Assignment 1

Abdominal Assessmentin This Assessment 1 Assignment You Will Analyze

Abdominal Assessmentin This Assessment 1 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 identify five possible conditions that may be considered as a differential diagnosis for this patient.

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 Paper For Above instruction

Introduction

Abdominal pain is a common presentation in emergency and primary care settings, often signaling a range of potentially serious conditions. Accurate assessment requires a comprehensive understanding of the patient's history, physical examination, and appropriate diagnostic testing. This paper analyzes a complex case involving a 65-year-old male presenting with epigastric pain, evaluates the subjective and objective data, and discusses potential diagnoses, supporting evidence-based decision-making processes.

Analysis of the Subjective Data

The subjective portion provides essential initial details, such as the nature, location, duration, and progression of the pain, along with associated symptoms like vomiting. The chief complaint, "My stomach has been hurting for the past two days," establishes symptom duration but lacks specificity regarding pain characteristics—quality, intensity, aggravating or relieving factors, and exact timing. While the history notes episodic epigastric pain radiating into the back, it does not clarify whether the pain is constant or intermittent, severity, or response to medications.

Additional details necessary include the pain's onset details, exact characteristics (sharp, dull, burning), relieving factors (food, antacids, rest), and aggravators (movement, eating). Clarification about the vomit's appearance—whether it contains blood, bile, or undigested food—would enhance diagnostic accuracy. Expanding on past medical history details, such as the date of hypertension diagnosis, previous hospitalizations, or treatments for Gerd, is crucial. Information about medication adherence, any recent weight changes, and recent dietary habits can further inform the assessment. Lastly, a detailed social history including alcohol quantity and frequency, smoking history, drug use, religious or cultural practices, and dietary patterns would enrich understanding of risk factors.

Analysis of the Objective Data

The objective data includes vital signs, physical examination findings, and initial diagnostics. The vitals indicate hypotension (BP 91/60) and a normal temperature, which could suggest hypovolemia or systemic illness. However, oxygen saturation and BMI are missing, limiting full assessment of systemic status. Physical exam findings reveal epigastric tenderness with guarding but absence of rebound, suggesting localized inflammation or irritation without peritonitis. Cardiac and respiratory exams are unremarkable, and skin assessment shows no rash or lesions, ruling out some dermatologic causes.

Additional objective data to be recorded includes detailed abdominal auscultation (bowel sounds), percussion, and palpation notes, including any masses, distention, or abnormal pulsations suggesting AAA. Inspection for signs like jaundice, scleral icterus, or supraclavicular lymphadenopathy could assist in differential diagnosis. Laboratory values—such as complete blood count, liver function tests, amylase, and lipase—are essential and are now missing. Imaging results, including ultrasound and CTA, are noted but should be supplemented with findings like aneurysm size, presence of thrombus, or evidence of perforation or inflammation in the pancreas or gastric area.

Support for the Assessment

The clinical presentation aligns well with pancreatitis, given the epigastric pain radiating to the back, vomiting, and a history of alcohol use, although lab confirmation is crucial. Symptoms of AAA might include back pain, abdominal pulsation, or hypotension, but in this case, the physical findings do not fully support rupture or expansion. The absence of classic signs such as a pulsatile abdominal mass or sudden severe pain diminishes the likelihood but does not rule out a stable aneurysm.

The findings do not strongly support perforated ulcer; absence of peritoneal signs like rigidity or rebound tenderness diminishes that suspicion, but ongoing evaluation is needed. Diagnostic tests such as serum amylase and lipase, CT imaging, and ultrasound are necessary to confirm pancreatic or vascular pathologies.

Diagnostic Tests and Their Role

Recommended diagnostic tests include serum amylase and lipase levels, which are elevated in pancreatitis. An abdominal ultrasound provides a non-invasive assessment of gallstones, pancreatic inflammation, and aneurysm presence. A contrast-enhanced CT scan offers detailed visualization of the pancreas, abdominal vasculature, and potential perforations, enabling definitive diagnosis (Hamm, 2021). Laboratory liver function tests could reveal cholestasis or hepatic pathology contributing to symptoms.

The results guide diagnosis: elevated enzymes support pancreatitis, aneurysm visualization confirms or rules out AAA, and evidence of perforation or bleeding indicates urgent surgical intervention. These findings influence management, from supportive care to possible surgical repair.

Acceptance or Rejection of Current Diagnosis

The initial assessment of pancreatitis is supported by the history of alcohol use, epigastric pain radiating into the back, and vomiting. The absence of hypotension or shock suggests that AAA or perforation are less likely, although their possibilities remain. Based on available data, pancreatitis appears to be the most plausible diagnosis; however, ruling out AAA or perforated ulcer is essential via imaging. Therefore, the current diagnosis should be accepted provisionally pending confirmatory testing, with continued assessment to exclude other critical conditions.

Additional Differential Diagnoses

Considering the patient's presentation, three alternative conditions include:

  1. Cholelithiasis (Gallstones): Pain localized in the right upper quadrant or epigastric with radiations to back and nausea; occur post-fatty meal (NCBI, 2021). Ultrasound can confirm diagnosis by detecting stones or biliary dilation.
  2. Gastritis or Gastric Ulcer: Nausea, epigastric pain, and vomiting, especially in alcohol users, suggest mucosal inflammation; endoscopy and H. pylori testing assist diagnosis (Chung & Shelat, 2017).
  3. Peptic Ulcer Disease: Epigastric pain related to meals, with possible gastrointestinal bleeding signs like hematemesis or melena; confirmed via endoscopy (Chung & Shelat, 2017).

In summary, thorough assessment, including history, physical examination, laboratory, and imaging studies, is critical to delineate these potential diagnoses and guide effective management.

Conclusion

This comprehensive analysis underscores the importance of detailed subjective and objective assessments in complex abdominal pain cases. Although initial data suggest pancreatitis, the possibility of AAA or perforated ulcer remains. Critical diagnostic testing, especially laboratory enzymes and imaging, is necessary to confirm the suspected diagnosis while ruling out other emergent conditions. Accurate documentation, systematic evaluation, and evidence-based decision-making are vital to optimizing patient outcomes in abdominal emergencies.

References

  • Chung, K. T., & Shelat, V. G. (2017). Perforated peptic ulcer - an update. World Journal of Gastrointestinal Surgery, 9(1), 1–12.
  • Hamm, R. G. (2021). Acute Pancreatitis: Causation, Diagnosis, and Classification Using Computed Tomography. Radiologic Technology, 93(2), 197–219.
  • Legg, J. S., & Legg, L. M. (2016). Abdominal Aortic Aneurysms. Radiologic Technology, 88(2), 145–165.
  • MedlinePlus. (n.d.). Fecal Occult Blood Test (FOBT). Retrieved from https://medlineplus.gov/ency/article/003586.htm
  • MedlinePlus. (n.d.). Gastritis. Retrieved from https://medlineplus.gov/gastritis.html
  • Merck Manual. (2021). Acute Cholecystitis. Retrieved from https://www.merckmanuals.com/professional/gastrointestinal-disorders/gallbladder-and-bile-duct-disorders/acute-cholecystitis
  • Tirumala, V. R. M. M., & Ramasubbaiah, R. (2019). Cholecystitis. Magill’s Medical Guide (Online Edition).

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