A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ;

Assignment 1: Lab Assignment: Assessing the Abdomen

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A male went to the emergency room for severe midepigastric abdominal pain. He was diagnosed with AAA ; however, as a precaution, the doctor ordered a CTA scan.

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 Lab Assignment, you will analyze an Episodic 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.

To Prepare

Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

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

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. CORE SKILL: abdominal pain is triaged by LOCATION plus ONSET plus the presence of peritoneal signs. And the specific lesson embedded in this case is that the DIAGNOSIS DRIVES THE WORKUP — an AAA is not a diagnosis you confirm casually.
THE EXAM SEQUENCE IS DIFFERENT HERE and graders check it: INSPECT → AUSCULTATE → PERCUSS → PALPATE. Auscultation comes BEFORE palpation because palpating first alters bowel sounds. Palpate the tender area LAST. This single ordering point is worth free marks.
ABOUT THIS CASE — AAA: the classic triad is abdominal/back pain, a PULSATILE ABDOMINAL MASS, and hypotension. Risk factors: age >65, male, smoking (the strongest modifiable risk factor), hypertension, atherosclerosis, family history. A RUPTURING AAA is a surgical emergency with very high mortality. NOTE THE CLINICAL REASONING PROBLEM IN THE STEM: a patient diagnosed with AAA who is stable enough for CTA is being evaluated for operative planning — but if the patient were unstable, imaging delay would be inappropriate and bedside ultrasound plus immediate surgical consult would be indicated. Also flag: CTA uses IODINATED CONTRAST, so renal function and contrast allergy must be assessed — and in a hypotensive patient, contrast nephropathy risk rises. Critiquing the documentation on these grounds is exactly what the “lab assignment” format is asking for.
MIDEPIGASTRIC PAIN DIFFERENTIAL — build it systematically: AAA; PANCREATITIS (epigastric pain radiating to the BACK, relieved by leaning forward; lipase is more specific than amylase; Cullen’s and Grey Turner’s signs in hemorrhagic disease; causes — gallstones and alcohol account for most); PEPTIC ULCER DISEASE (and PERFORATION — sudden severe pain, rigid board-like abdomen, free air under the diaphragm on upright film); GASTRITIS/GERD; MYOCARDIAL INFARCTION — an inferior MI can present as epigastric pain with nausea, and this is a classic miss, especially in women, older adults, and patients with diabetes. GET AN EKG. Also: mesenteric ischemia (pain OUT OF PROPORTION to exam findings — the key phrase), biliary disease, bowel obstruction.
PERITONEAL SIGNS: guarding, rigidity, REBOUND tenderness, and — more reliable and kinder — pain on percussion or with a jarring maneuver. Rovsing’s, psoas, obturator, Murphy’s sign (RUQ), McBurney’s point (RLQ).
FOR THE ASSIGNMENT (which is a critique of a documented note): assess whether the subjective is complete (OLDCARTS, full ROS, meds, allergies, social/family history), whether the objective supports the assessment, whether the diagnostic tests ordered are APPROPRIATE and JUSTIFIED, and whether you accept or reject the stated diagnosis. Then supply your own 3–5 differentials with rationale. Explicitly identify what is MISSING — vital signs, EKG, lab values, a full abdominal exam. Missing data is a finding.
DIAGNOSTICS TO KNOW: CBC, CMP, lipase, LFTs, lactate (ischemia), urinalysis, hCG in any woman of childbearing age (ectopic pregnancy is on every female abdominal-pain differential), upright chest/abdominal film for free air, ultrasound (first-line for biliary and for AAA at the bedside), CT with contrast.