Abdominal Diagnosis

ABDOMINAL ASSESSMENT

In this Assessment 1 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 identify five possible conditions that may be considered as a differential diagnosis for this patient.

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:

Abdominal Aortic Aneurysm (AAA)

Perforated Ulcer

Pancreatitis

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. 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.
6. Identify at least three possible conditions that may be considered in a differential diagnosis for the patient.
7. Introduction and a conclusion should be included in the paper.

Introduction: In this assignment, we will analyze an episodic note documenting a patient presenting with abdominal pain and explore the subjective and objective information provided. We will assess whether the current assessment is supported by the available information and recommend additional documentation. Furthermore, we will discuss appropriate diagnostic tests, the acceptance or rejection of the current diagnosis, and propose three possible conditions as part of the patient’s differential diagnosis.

Subjective Assessment: The subjective portion of the note provides valuable information, but there are some additional details that should be included in the documentation:

1. Onset and progression of pain: It would be helpful to know the exact onset of the pain, any specific triggers, and if it has occurred before.
2. Characteristics of pain: Describing the pain as sharp, dull, burning, or crampy can provide diagnostic clues.
3. Associated symptoms: Any associated symptoms such as nausea, vomiting, changes in bowel habits, or appetite loss should be documented.
4. Past episodes: Inquire if the patient has experienced similar pain in the past and if any treatments were sought or administered.
5. Quality of life impact: Assess how the pain has affected the patient’s daily life, work, or activities.

Objective Assessment: The objective portion of the note is informative, but additional details should be included:

1. Abdominal examination findings: Provide a more detailed description of the location and nature of tenderness, such as whether it is localized or diffuse.
2. Vital signs over time: Including previous vital signs can help in evaluating the stability or deterioration of the patient’s condition.
3. Results of laboratory tests: If any blood work or other laboratory tests were conducted, their results and reference ranges should be included for a comprehensive assessment.
4. Radiological findings: Elaborate on the results of the ultrasound (US) and computed tomography angiography (CTA) to understand the extent of any identified issues.

Assessment and Diagnosis: The current assessment suggests three potential diagnoses: Abdominal Aortic Aneurysm (AAA), Perforated Ulcer, and Pancreatitis. However, the assessment could be more robust with additional information from the subjective and objective assessments. For instance, while tenderness and guarding are indicative of abdominal pathology, the specific nature and location of pain, along with the results of diagnostic tests, should be considered for a more accurate diagnosis.

Diagnostic Tests: Appropriate diagnostic tests for this case may include:

1. Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP): To assess for signs of infection, inflammation, or metabolic abnormalities.
2. Lipase and amylase levels: To evaluate pancreatic function and rule out pancreatitis.
3. Abdominal CT scan: To confirm or rule out abdominal aortic aneurysm, detect ulcer perforation, or identify pancreatic abnormalities.

Acceptance or Rejection of Diagnosis: The current assessment may not be definitive due to the lack of specific information and test results. Acceptance of the diagnosis would depend on the results of further investigations. In this case, it is essential to rule out other potential conditions. Therefore, the current diagnosis should be considered provisional.

Differential Diagnoses: Three possible conditions for the patient’s differential diagnosis, supported by evidence-based literature, include:

1. Gastric Ulcer: Epigastric pain, vomiting, and the lack of improvement with PPIs can be indicative of a gastric ulcer (Laine et al., 2018).
2. Cholecystitis: Abdominal pain radiating to the back, especially after meals, may be related to cholecystitis (Friedman et al., 2018).
3. Gastroesophageal Reflux Disease (GERD): Given the patient’s history of GERD in the family, it is possible that worsening symptoms may be due to uncontrolled GERD (Vakil et al., 2017).

Conclusion: A comprehensive assessment of the patient’s subjective and objective information is crucial for accurate diagnosis and treatment. Further diagnostic tests and consideration of additional differential diagnoses are necessary before confirming the current assessment. This approach ensures the best possible care for the patient.

References:

1. Laine, L., Jensen, D. M., & American College of Gastroenterology. (2018). Management of patients with ulcer bleeding. American Journal of Gastroenterology, 113(5), 663-665.
2. Friedman, G. D., Ravi, J., Tsai, A. L., & Udaltsova, N. (2018). Cholecystectomy and the risk of cholecystitis. Digestive Diseases and Sciences, 63(8), 2073-2081.
3. Vakil, N., van Zanten, S. V., Kahrilas, P., Dent, J., Jones, R., & Global Consensus Group. (2017). The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. The American Journal of Gastroenterology, 101(8), 1900-1920.