A male went to the emergency room for severe mid-epigastric abdominal pain. He was diagnosed with AAA; however, as a precaution, the

The Case Study/Scenario: 

Jason, a 13-year-old male comes in with Mom complaining of painful swallowing. Started yesterday as a “really bad sore throat” made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Children’s Motrin which made his fever better but did not help his sore throat. He reports his symptoms are especially, worse during nighttime. His tonsils are 2+ and erythematous, tonsil stones are present on the right side. He has white patches on his tongue

The Question

In this Case Study 

1. Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study.

2. Consider case studies of abnormal findings from patients in a clinical setting. 

3. Determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted.

4. How would the results be used to make a diagnosis?

5. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.

6. Formulate at least Five differential diagnoses with several possible conditions and justify why you selected each.

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Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 

· Chapter 6, “Vital Signs and Pain Assessment” This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.

 

· Chapter 18, “Abdomen” In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 3, “Abdominal Pain” This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.

Chapter 10, “Constipation” The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.

Chapter 12, “Diarrhea” In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.

Chapter 29, “Rectal Pain, Itching, and Bleeding” This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

 

These sections below explain the procedural knowledge needed to perform gastrointestinal procedures.

Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520)

Note:  Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Key points. In Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V. (2021). Changing paradigms in the management of acute uncomplicated diverticulitis. Scandinavian Journal of Surgery, 110(2), 180–186. https://doi.org/10.1177/14574969211011032

Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain in the elderly patient: Point-of-care ultrasound diagnosis of small bowel obstruction. Clinical Practice and Cases in Emergency Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029

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THE RUBRIC

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.	10 (10%) - 12 (12%) The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.	10 (10%) - 12 (12%) The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?	14 (14%) - 16 (16%) The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?	18 (18%) - 20 (20%) The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would 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 differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.	23 (23%) - 25 (25%) The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	5 (5%) - 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation.	5 (5%) - 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.	5 (5%) - 5 (5%) Uses correct APA format with no errors.

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WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2

WEEK 6 ASSIGNMENT 1: LAB ASSESSING THE ABDOMEN 2

Abdominal Assessment Case Study SOAP Note

Subjective:

•CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”

•HPI: JR, 47-year-old WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.

•PMH: HTN, Diabetes, hx of GI bleed 4 years ago

•Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs

•Allergies: NKDA

•FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD

•Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

•VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs

•Heart: RRR, no murmurs

•Lungs: CTA, chest wall symmetrical

•Skin: Intact without lesions, no urticaria

•Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

•Diagnostics: None

Assessment:

•Left lower quadrant pain

•Gastroenteritis

PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Subjective Analysis

According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questions to ask before the beginning exam (Ball,2015). Specifying which part of the abdomen with clarifying questions asked during the ROS which is missing altogether. Patient reports of not using his medications would go under medications the last time he took them, needs to identify the reason for each medication, and why stopped. Negative finding for colon cancer listed could have been a differential diagnosis consideration, then needs to be listed under the Assessment section. Lastly, the family history is required to go back to three generations with 2 out of 3 documented. It seems as if this practitioner got sidetracked with his ROS and forgot to note the rest of the PMHx or forgot to finish it. The lifestyle and exercise questions for diabetes and hypertension are good practice and required for proper medical documentation (Ball, Dains, Flynn, Solomon, & Stewart, 2019). CAGE screening ruling out alcoholism. How much is “occasional” drinking? How many, how often, and any repercussions?

The objective portion of the note and additional information that should be included in the documentation.

Objective Analysis

In the objective part of the SOAP note, the documentation still needs more information on the general appearance of the patient. This includes the rate at which the patient answers questions, if all questions are answered appropriately, if the hygiene of the patient is good, the mood, and the posture. The result of the inspection and percussion of the abdomen was not given, although the auscultation was done and was noted to be hyperactive and pain to the left lower quadrant.

Physical examination is out of order. Systems uniformly listed in a certain order to match head to toe assessments. The general assessment is completely missing from this section. Only positive findings and pertinent negative findings needed for the objective part of the SOAP note. The body systems that are listed need to be in a particular order when used HEENT before Neck, Neck before Chest, and so on. The SOAP for the case study would be VS General, Skin, Chest, Abdomen, and Genitourinary (Ball et al., 2019). These areas contain all the organs that may be the cause of abdominal pain. There were two positive findings in which this practitioner needed to use palpation and a stethoscope. The negative results for the rest of the examination need documentation for palpation and auscultation. Lastly, if JR has a history of GI bleed, where is the CBC, skin pallor, cap refill? If JR is a diabetic with diarrhea, where is his blood glucose and CMP? What is the character of LLQ palpation findings? Mass/no mass. Rebound tenderness? Sharp/dull does it travel? The practitioner might have suspected with the mention of the father having no colon cancer. Needed are CBC, CMP, HbA1c, Abd x-ray, stool guaiac, and stool WBC. Also, the colorectal exam performed along with prostate screening. Referral for EGD/colonoscopy, especially with his high risk for colon cancer and history of GI bleed (Sullivan*, 2019).

Is the Assessment Supported by S/O Information?

The assessment is partly supported and partly not supported by the objective and subjective information. For example, the Gastroenteritis assessment is supported by the chief complaint of the patient where she states stomach pain, diarrhea, and nausea. According to Martin (2016), the symptoms of Gastroenteritis include stomach pain, watery diarrhea, fever, nausea, cramping and headache. The subjective data the patient reported supported the gastroenteritis assessment however, the objective part of the SOAP note is not considered in the assessment. The patient complained of generalized pain which is totally different from the left lower quadrant (LLQ) pain that was collected in the Objective data, but the left lower quadrant could also be a referred pain and need to be investigated further because serious medical conditions disguise with GI symptoms.

Diagnostic tests would be appropriate for this case, and how the results would be used to make a diagnosis

1. Stool occult test: This test will find out if there is blood in the stool or not. This is not a normal result. If there is presence of blood in the stool which cannot be clearly seen by the eye, then it would be an indication of a serious issue in the upper digestive tract.

2. Blood test such as Complete blood count (CBC), Comprehensive metabolic panel (CMP) Magnesium and Phosphorus and stool sample. Since the patient is having a low-grade fever, it is important to rule out an infection. The CMP would give a present health status of the kidneys, liver and electrolytes since the patient complains of frequent diarrhea.

3. Liver function test – as the name suggests, liver function tests are carried out to determine the functioning of the liver. The main role of the liver is to get rid toxic toxins from the body, and if this is not happening then the test could show if the liver is damaged. If toxins are not removed from the body, it could result to a lot of pain that could be felt in the abdomen.

4. Ultrasound of the abdomen – This is a painless procedure imaging that allows one to have a good view of all the organs in the abdomen which includes the kidneys, liver, gall bladder, spleen and pancreas.

5. X-ray of the Abdomen and CT abdomen and pelvic would be done lastly due to cost and after any positive result of the above test.

Would I accept or reject the diagnosis in the SOAP?

I would not accept the diagnosis due to the objective data of left lower quadrant pain. The subjective data point mostly to gastroenteritis, the patient has a low grate fever, diarrhea, nausea and vomiting and abdominal pain. The three possible conditions that may be considered as a differential diagnosis for this patient include:

1. Intestinal obstruction

This happens when food is blocked from passing through the large or the small intestines. According to the Mayo Foundation of Medical Education and Research (2015), the symptoms of intestinal obstruction include abdominal pains, stomach cramps, vomiting, constipation, and nausea.

1. Gallstones

This refers to solid materials that form I the gallbladder thereby leading to blockage. According to WebMD (2017), its symptoms include nausea, vomiting, indigestion, and stomach pain.

1. H. Pylori

This is infection of the stomach by bacteria. According to Colledge and Cafasso (2015), its symptoms include abdominal pain, vomiting, loss of appetite, bloating, and nausea.

1. Diverticulitis

This is the most common cause of the left lower quadrant pain, It is the inflammation of diverticula, that is caused by a tear, infection or swelling of the diverticula, which are small pouches which is caused by the weakness of the colon. The symptoms include left lower abdomen pain, fever, nausea, vomiting and abdominal tenderness. This is most likely my pick of diagnosis because it has both the subjective and objective data present. Although according to Almerie & Simpson (2015) diverticulosis of the bowel would have been diagnosed before a diagnosis of diverticulitis can be confirmed, this is best done with a CT abdomen.

1. Ulcerative colitis

Due to the patient history of GI bleed, this is a differential diagnosis. The symptoms include diarrhea, the color of stool is not received in the subjective data so there may be likely some trace of blood, abdominal pain, fatigue, fever, urgency to defecate. A stool sample test with a positive white blood cells would rule out ulcerative colitis and would also make us aware if there are other disorders.

References

Colledge, H., & Cafasso, J. (2015, September 13). H. pylori Infection: Causes, Symptoms, and Treatment. Retrieved from http://www.healthline.com/health/helicobacter-pylori?m=0#overview1

Martin, L. J. (2016, May 1). Gastroenteritis (Stomach 'Flu'). Retrieved from https://www.webmd.com/digestive-disorders/gastroenteritis#1

Mayo Foundation for Medical Education and Research. (2015, December 31). Intestinal obstruction Symptoms and causes – Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/dxc-20168463

WebMD. (2017). Gallstones Picture, Types, Causes, Risks, Symptoms, Treatments. Retrieved from http://www.webmd.com/digestive-disorders/gallstones#2

Ball, J. 2 W., Dains, J.  E., Flynn, J.  A., Solomon, B.  S., & Stewart, R. W. (2015). 2Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Almerie, M. Q., & Simpson, J. (2015). Diagnosing and treating diverticular disease. The Practitioner, 259(1785), 29. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=26591654&site=ehost-live&scope=site

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