Identify possible conditions that may be considered in a differential diagnosis for a patient with Abdomen SOAP
Assessing the Abdomen SOAP Note Case Study Nursing Paper
Assessing the Abdomen SOAP Note Case Study Nursing Paper
APA format 3 peer review references Please follow instructions on the assignment
Assessment 1: Assessing the Abdomen
A woman went to the emergency room for severe abdominal cramping. She was diagnosed with diverticulitis; however, as a precaution, the doctor ordered a CAT scan. The CAT scan revealed a growth on the pancreas, which turned out to be pancreatic cancer—the real cause of the cramping.
Because of a high potential for misdiagnosis, determining the precise cause of abdominal pain can be time-consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen.
In this assignment, you will analyze a SOAP 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 formulate a differential diagnosis with several possible conditions.
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Abdominal Assessment
SUBJECTIVE:
- CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
- HPI: JR, 47 yo 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, hyperctive 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.
To prepare:
With regard to the SOAP 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.
To complete this Assessing the Abdomen SOAP Note Case Study Nursing Paper:
- 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 3 different references from current evidence based literature. Assessing the Abdomen SOAP Note Case Study Nursing Paper.
ADDITIONAL INFORMATION;
Identify possible conditions that may be considered in a differential diagnosis for Abdomen SOAP
Introduction
Abdomen SOAP is a syndrome that causes abdominal pain, diarrhea, vomiting and weight loss. The cause of this condition is unknown but it can have many possible causes including but not limited to: gastroenteritis caused by intestinal infections such as norovirus; colitis (inflammation or infection of the colon); pancreatitis (inflammation of the pancreas); hepatitis A and B; functional GI disorders like irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD).
Hepatitis
Hepatitis is inflammation of the liver. It can be caused by viruses, alcohol and autoimmune disorders like lupus or Hashimoto’s thyroiditis.
Symptoms include fever, fatigue, nausea and vomiting, abdominal pain and jaundice (dark urine) that may last up to six weeks after exposure to hepatitis virus. Diagnosis is by blood tests for markers like ALT or AST which indicate liver damage; also look for antibodies specific for hepatitis A or B viruses in your serum.
General
A thorough history of the patient’s medical and social history is important in making a differential diagnosis. The following questions should be asked:
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How long has he had symptoms?
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Has he recently been ill or injured? (Has he had surgery or an injury to his abdomen?)
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What medications are being taken currently, and what are their side effects?
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What foods do you eat regularly, and which ones make your stomach upset when they’re eaten together (e.g., spicy foods)?
Precipitating cause(s)
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Pain that is worse with eating, or after eating
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Pain that is worse with bending
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Pain that is worse with coughing
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Pain that is worse with sneezing
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Pain that is worse with laughing
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Pain localized to the right lower quadrant of the abdomen (RLEQ)
Chronic fatigue or weakness
Chronic fatigue or weakness is a common symptom of chronic fatigue syndrome. It can also be a side effect of medications, such as antidepressants and pain killers.
Other conditions that may be considered in the differential diagnosis for abdominal symptoms include:
Functional abdominal pain syndrome
The diagnosis of functional abdominal pain syndrome (FAPS) is made when the patient’s symptoms are consistent with the diagnosis, but no other cause for the abdominal pain is identified.
The patient’s symptoms must not be better explained by a medical disorder that causes chronic or recurrent abdominal pain.
Rectal bleeding, hematochezia
Rectal bleeding, hematochezia is a differential diagnosis to consider when the patient presents with abdominal pain or rectal bleeding. The patient may be experiencing hemorrhoids, ulcerative colitis, diverticulosis or even cancer.
Hemorrhoids (commonly known as piles) are common in older adults and occur when the walls of the large intestine become swollen due to increased pressure on them caused by straining during defecation. Patients who have had many children can also develop this condition because of increased pressure on the anal canal during childbirth, which results in thickening of irritated tissue around their anus.[1] This can cause pain from constipation due to reduced mobility due to inflammation and hard stool formation within these narrowed spaces.[2]
Peptic ulcer disease
Peptic ulcer disease is a common cause of abdominal pain. The most common symptoms include:
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Abdominal pain, bloating, and/or vomiting.
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Nausea or vomiting that does not go away with rest.
Urinary retention, decreased libido and/or impotence
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Urinary retention, decreased libido and/or impotence
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Causes of urinary retention, decreased libido and impotence:
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Rheumatoid arthritis (RA) is a common cause of urologic dysfunction. In fact, it is one of the most common causes for men to seek medical attention for erectile dysfunction (ED). More than 1 million people in the US have RA; however, only about half of them will experience some degree of ED at some point during their lifetime. In general, men with RA are twice as likely to develop ED than those without RA but may also be more likely to experience Peyronie’s disease or other forms of penile deformity due to scarring from physical trauma such as surgery or injury. It is important to note that not all men who have had surgery will develop this condition; however many factors can contribute towards developing this condition after having had surgery such as smoking cigarettes or using recreational drugs like alcohol while recovering from an invasive procedure such as prostatectomy which requires frequent visits back home because they need constant care throughout recovery time period following the operation itself (which takes place over several months).
Abdominal distention & bloating, belching and reflux (heartburn), bowel changes & diarrhea, nausea and/or vomiting, rectal pain or discomfort, melena (black tarry stools) and hematochezia.
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Abdominal distention and bloating
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Belching and reflux (heartburn)
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Bowel changes
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Diarrhea
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Nausea and vomiting
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Rectal pain or discomfort, melena (black tarry stools), hematochezia (bright red blood per rectum).
These are all possible conditions that may need to be considered in a differential diagnosis for a patient with Abdomen SOAP
These are all possible conditions that may need to be considered in a differential diagnosis for a patient with Abdomen SOAP. It is important to consider all possible conditions when making a diagnosis, as this is what differentiates a good doctor from an average one.
Conclusion
These are all possible conditions that may need to be considered in a differential diagnosis for a patient with Abdomen SOAP.
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