Assessing the Abdomen and Gastrointestinal System

Assessing the Abdomen and Gastrointestinal System

Question One: Analysis of the Subjective Portion

The patient is a 65-year-old African American male with intermittent epigastric pain that radiates to the back and is not relieved with PPI use. He also experienced vomiting after a meal. Also, he is a hypertensive patient on metoprolol. His family history is significant of GERD, hyperlipidemia, and HTN. He has a history of alcohol and smoking but quit both two years ago.

Additional information that should be included in the documentation for subjective data is information on the eating pattern of the patient before developing the symptoms, including the quantities of food taken and types of food. Information on when the epigastric pain is often felt may help in the diagnosis. The patient should be asked whether the pain worsens on lying down. A history of NSAID use should also be interrogated. Long-term NSAID use has been implicated in gastrointestinal disorders.

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Question Two: Analysis of the Objective Portion

The patient had a temperature of 98.2 degrees, BP of 91/60 mmHg, RR of 16 breaths per minute, PR 76 beats per minute, HT of 6’10”, and WT 262 lbs. The patient had a regular heart rate and rhythm, no murmurs, and a symmetrical chest wall. Abdominal examination revealed tenderness in the epigastric region with guarding but without rebound or mass. Additional information on physical examination documentation is information on the presence of anemia. The caregiver should assess for signs of anemia in the patient. The healthcare provider should also assess for fatigue, dental erosion, and dysphonia. Another piece of information that may be obtained by physical examination is the presence of a productive cough. Bloodstain cough and stool are often indicative of mucosal perforations that characterize some gastric pathologies.

Question Three: Assessment

Assessment findings revealed pancreatitis, abdominal aortic aneurysm, and perforated ulcer as likely etiologies for the patient’s presentations. These assessment findings are, to a small extent, supported by subjective and objective information. The patient presented with epigastric pain that radiates to the back and is not relieved with PPIs and an episode of vomiting. Acute pancreatitis commonly presents with epigastric abdominal pain that also radiates to the back. Acute pancreatitis is also associated with nausea and vomiting. This warrants the admission of this assessment finding.

The assessment finding for an aortic aneurysm was not warranted in this case. While abdominal aortic aneurysm sometimes presents with abdominal and back pain, the pain is often sudden in onset. Palpation of the abdomen in an aortic aneurysm also reveals a non-tender and pulsatile abdominal mass. In the case above, the palpation revealed a tender abdomen, thus warranting the exclusion of this assessment.

The assessment finding for perforated ulcers is also not warranted in this case. Perforated ulcers often result in internal bleeding. This can be indicated by the presence of hematemesis, melena stool, fatigue, noticeable heartbeats, and shortness of breath (Malik et al., 2022). None of these were observed during the patient’s physical examination. The patient’s manifestation did not indicate the presence of a perforated ulcer, thus warranting the exclusion of this assessment.

Question Four: Appropriate Diagnostic Tests

The most appropriate diagnostics for the patient include an abdominal ultrasound and computed tomography of the abdomen. Abdominal ultrasound is an effective tool in the diagnosis of pancreatitis. This diagnostic tool helps in the detection of choledocholithiasis and the dilation of the bile duct. CT scan is also recommended where the patient’s manifestation fails to improve after a period of sustained fluid resuscitation or when the presentations are equivocal. Essentially, CT scans enable the detection of parenchymal changes seen in pancreatitis and can thus help in confirming the disease.

Question Five: Analysis of the Current Diagnosis and Differential Diagnoses

The patient presentations are consistent with acute pancreatitis. Acute pancreatitis presents with epigastric abdominal pain and is commonly accompanied by vomiting. Pain observed in acute pancreatitis is sharp, severe, and persistent and is made worse by the assumption of the supine position (Chatila et al., 2019). This diagnosis is confirmed by the failure of PPIs to relieve the patient’s manifestations. PPIs maintain effectiveness in gastric disorders such as PUD and GERD that have similar presentations as acute pancreatitis. A failed response to PPI may be indicative of acute pancreatitis.

Possible conditions that may be considered differential diagnoses for this patient include GERD, PUD, and gastric cancer. GERD, gastroesophageal reflux disease, often presents with a burning sensation in the lower retrosternal area and the epigastrium. This diagnosis is ruled out because of the additional manifestations of vomiting and pain radiating to the back that are not characteristic of the disease (Maret-Ouda et al., 2020). PUD presents with abdominal epigastric pain that radiates to the back and vomiting, as seen in the case (Malik et al., 2022). This diagnosis is, however, ruled out because of the failed response to PPIs. Gastric cancer has a similar presentation as PUD. However, it is defined by the presence of alarm symptoms such as melena stool and weight loss (Moala AlHazmi et al., 2021). Such is not the case in the patient case presented.

References

Chatila, A., Bilal, M., & Guturu, P. (2019). Evaluation and management of acute pancreatitis. World Journal of Clinical Cases, 7(9), 1006-1020. https://doi.org/10.12998/wjcc.v7.i9.1006

Malik, T., Gnanapandithan, K., & Singh, K. (2022). Peptic Ulcer Disease. Ncbi.nlm.nih.gov. Retrieved 4 October 2022, from https://www.ncbi.nlm.nih.gov/books/NBK534792/.

Maret-Ouda, J., Markar, S., & Lagergren, J. (2020). Gastroesophageal Reflux Disease. JAMA, 324(24), 2536. https://doi.org/10.1001/jama.2020.21360

Moala AlHazmi, R., Nasrallah Alfaraj, D., Nasser AlNaimi, S., Mohammed AlQahtani, S., Hamed AlJuwayed, M., Mohammed Zakriea, H., & Foula, M. (2021). A Rare Presentation of Gastric Carcinoma with Gastric Perforation and Septic Shock. Cureus. https://doi.org/10.7759/cureus.18657

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This week, you will explore how to assess the abdomen and gastrointestinal system.

Learning Objectives

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.
Identify concepts, theories, and principles related to advanced health assessment.
Assignment 1: Lab Assignment

You will analyze an Episodic note case study (listed below) that describes abnormal findings in patients seen in a clinical setting. WRITE THIS UP AS A NARRATIVE so that you are able to correctly explain the analysis. 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.

Please DO NOT write this up in a soap note format.

You are NOT completing a soap note but analyzing all the information provided and discussing in your narrative what information is missing. You need to take all of the information presented into consideration to determine what is missing. Then you what consider and what is normally documented in the soap note for the various parts of the note. Please use your textbook guide to clinical documentation to help with this assignment. It will be a great source to use for this assignment as well as the required resources for this week.

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: 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 there 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.