NURS 6512: Abdominal Assessment Subjective Episodic Case
Introduction Assignment Overview:
This paper analyzes a SOAP (Subjective, Objective, Assessment, and Plan) note for a patient presenting with severe abdominal pain and diarrhea, aiming to improve the quality of documentation and diagnostic accuracy. The patient, J.R, a 47-year-old female, sought medical attention due to generalized abdominal pain that began three days ago. This assessment is part of NURS 6512: Week 6 Lab Assignment 1, focusing on abdominal assessment. The objective is to provide a comprehensive analysis of the SOAP note, identify areas for improvement, and suggest additional information and diagnostic tests to enhance the assessment’s quality.
The Student’s Role in the Abdominal Assessment Subjective Episodic NOTE Case Study Assignment:
As a student in NURS 6512, your role is to carefully analyze and interpret the provided episodic note, which details a patient’s abdominal complaints and clinical presentation. You will assume the role of a healthcare practitioner responsible for assessing and documenting the patient’s condition. Your analysis will be structured in accordance with the SOAP format to facilitate clear communication and decision-making in a clinical setting.
Subjective Assessment:
The patient reports severe abdominal pain lasting for three days and describes it as, “My stomach hurts, I have diarrhea, and nothing seems to help.” The patient has not taken any medications to alleviate the pain due to uncertainty about the appropriate choice. She rates her current pain level as 5/10, but it was as high as 9/10 when the pain initially started. She experiences nausea after eating. J.R.’s medical history includes hypertension, diabetes, and a gastrointestinal bleed four years ago. Her current medications include Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, and Lantus 10 units qhs. She has no known drug allergies. Family history reveals her father has type 2 diabetes and hypertension, while her mother has hypertension, hyperlipidemia, and GERD. She is married with three children, denies tobacco use, and admits to occasional alcohol consumption.
The provided subjective data is informative, but additional information is necessary. Relevant data to include in the SOAP Note should encompass the following (Ball et al., 2019):
- Review of Systems: A comprehensive review of systems to identify any associated symptoms or systemic manifestations related to abdominal pain.
- Recent Travel or Exposure: Inquire about recent travel or exposure to contaminated water or food, as it could indicate infectious etiology.
- Detailed Nausea Assessment: Gather specific details about the nausea, including severity, timing, triggers, and associated symptoms.
- Dietary Changes: Explore if there have been any recent changes in diet or food intake, which may be related to the symptoms.
- Diarrhea Characteristics: Document the duration and characteristics of diarrhea, including consistency, frequency, and presence of mucus, or blood.
- Weight Changes: Inquire about any recent weight changes, as unexplained weight loss can be a significant symptom.
Objective Assessment:
Vital signs indicate a temperature of 99.8°F, respiratory rate of 16 breaths per minute, weight of 248lbs, blood pressure of 160/86mmHg, pulse rate of 92 beats per minute, and a height of 5’10”. A cardiovascular assessment reveals a regular rhythm and rate without murmurs. Her chest walls are symmetrical, and lung auscultation reveals clear breath sounds. The patient’s skin appears without visible urticaria or lesions. An abdominal assessment indicates softness and hyperactive bowel sounds, along with pain in the left lower quadrant (LLQ).
Additional information is required to establish a comprehensive patient profile and consider potential differential diagnoses. Essential data to include are as follows (Ball et al., 2019):
- Bowel Movement Characteristics: Perform a thorough assessment of bowel movements, noting the presence of mucus or blood, frequency, and consistency.
- Previous Abdominal Tests: If available, include findings from prior abdominal diagnostic or imaging tests to provide a historical context.
- Pain Description: Elaborate on the pain in the left lower quadrant (LLQ) by documenting relieving/aggravating factors, onset, intensity, and nature.
- Additional Physical Exams: If clinically indicated, perform a rectal examination and document relevant findings.
- Abdominal Palpation: Describe the results of abdominal palpation to assess for tenderness, masses, or other abnormalities.
Diagnostic Tests:
To further evaluate the patient’s condition and support the assessment, the following diagnostic tests are recommended:
- Electrolyte Panel: Conduct an electrolyte panel to assess for electrolyte imbalances or dehydration, which can be associated with gastrointestinal conditions (Dains et al., 2019).
- Stool Culture and Sensitivity: Perform a stool culture and sensitivity test to identify infectious etiologies responsible for diarrhea (Ball et al., 2019).
- Abdominal Imaging: Consider abdominal imaging, such as a CT scan, if the patient’s condition does not improve or worsens, or if signs of complications arise (Colyar, 2015).
- Complete Blood Count (CBC): Order a CBC to identify signs of inflammation or infection, which can help guide the diagnosis (Dains et al., 2019).
- Hemoglobin A1c (HbA1c) Test: In patients with diabetes, conduct an HbA1c test to assess long-term blood sugar control (Dains et al., 2019).
These tests help confirm the diagnosis of gastroenteritis and rule out other potential causes of the patient’s ailment. Additionally, they guide physicians in recommending appropriate treatment interventions and provide insights into J.R.’s overall health status, identifying underlying conditions that may require further specialist consultation.
Assessment and Differential Diagnoses:
Primary Diagnosis:
Gastroenteritis: This aligns with the patient’s symptoms of abdominal pain, diarrhea, and nausea, lasting a few days and often caused by contaminated sources (Dains et al., 2019). Gastroenteritis typically lasts for a few days and can be transmitted through contact with contaminated surfaces, water, or food.
Differential Diagnoses:
- Diverticulitis: While less likely, diverticulitis presents with infection or inflammation of the diverticula in the colon, causing fever, changes in bowel movements, and pain in the lower left quadrant.
- Inflammatory Bowel Disease (Ulcerative Colitis or Crohn’s Disease): While less probable, these conditions may present with abdominal pain and diarrhea, typically with systemic symptoms (Dains et al., 2019).
- Irritable Bowel Syndrome (IBS): Although not a primary diagnosis candidate, IBS can cause altered bowel habits and abdominal pain, often accompanied by bloating (Adriani et al., 2018).
- Gastrointestinal Malignancy: While improbable due to the acute onset of symptoms, it’s essential to consider this possibility, as it presents with weight loss, nausea and vomiting, early satiety, and abdominal pain (Franke et al., 2017).
Conclusion
Revising and enhancing the SOAP note analysis for J.R’s abdominal pain assessment ensures a more comprehensive evaluation, appropriate diagnostic consideration, and a thorough examination of potential differential diagnoses, thus improving the quality of care provided to the patient. The recommended diagnostic tests will help confirm gastroenteritis and exclude other potential causes, providing a clear path for effective management.
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