Abdominal Assessment Discussion Paper

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ztnyber

Health Medical

Question Description

I'm working on a nursing question and need an explanation and answer to help me learn.

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:

  1. Abdominal Aortic Aneurysm (AAA)
  2. Perforated Ulcer
  3. Pancreatitis

DIRECTIONS:

With regard to the SOAP note case study provided, address the following:

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 or 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.

Explanation & Answer:
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Explanation & Answer

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1

Abdominal Assessment

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Abdominal Assessment
Analysis of the Subjective Portion and Additional Information
The subjective information discussed in the case study involves various aspects,
including the chief complaint, the body area experiencing discomfort, and the related symptoms.
Additional information needs to be sought to ensure an accurate diagnosis has been obtained.
Some additional subjective information required includes the patient’s response to various
treatments provided previously, what the patient believes might be the cause of the illness, and
whether he has experienced such a condition in the past.
Analysis of the Objective Portion and Additional Information
The objective data provided for the patient involve different aspects, especially the vital
signs and the condition of the critical organs. More objective information needed includes the
patient's mental status and the level of pain experienced. The facial expression when explaining
the pain, perfuse sweating, and abdominal bloating can also be included in the objective
information.
Whether the Assessment is supported by Subjective and Objective Information
The patie...

uraelcebsrffbe (119890)
UIUC

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