JR 47 yo WM complains of having generalized abdominal pain that started 3 days ago. He has no
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, 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.
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.
REQUIRED READINGS:
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 107, “X-Ray Interpretation: Chest (pp. 480–487)
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.
Expert Answer and Explanation
Abdominal Assessment
Assessment is a critical practice in nursing. Nursing assessment can be used to determine the current and future care needs of a patient (Ball, Dains, Flynn, Solomon & Stewart, 2019). Nursing assessment includes the recognition of abnormal versus normal physiology. The purpose of this assignment is to analyze the provided Episodic Note case study that describes abnormal findings in patients seen in a clinical setting and answer the provided questions.
Additional Subjective Data to be included in the Documentation
A lot of information was included in a subjective portion of the note. However, I feel that some critical data that can improve the assessment process are missing. For instance, the patient’s ethnic group was not mentioned. Some diseases are more prone in certain ethnic groups compared to others. Hence, identifying the race of the patient can help a nurse identify whether the client’s ethnicity is a risk factor for specific diseases.
Another important data that should be added in the subjective portion of the note is the review of systems. The review of systems is the process of reviewing a patient’s body systems by asking them a series of questions to identify symptoms the client may be experiencing (Dains, Baumann & Scheibel, 2019).
The nurse who prepared this note did not review JR’s body syst
ems and hence failed to identify any abnormalities with the systems. Information about immunizations should also be included in the subjective part. This information can help a nurse determine whether the patient is exposed to communicable diseases. The last information that should be included in the subjective part is the patient’s hobbies, what they like to do when free, whether they go to church and activities of daily living.
Additional Objective Data to be included in the Documentation
Objective data included in the assigned note can be used to determine a diagnosis. However, the following information should be added to the objective portion to make it unique and comprehensive. First, the general appearance of the patient should be added. Here, the nurse should describe whether the patient is alert, oriented, has acute distress, and answers questions properly (Ball et al., 2019).
The general appearance of the patient can help a nurse determine the severity of their health complaints. Second, the nurse would have noted whether the pulse was normal or not. Description of the pulse rate can help rule out any cardiovascular abnormality. Third, the nurse could have included an assessment of the patient’s cardiovascular and respiratory.
Dains et al. (2019) note that nurses should always assess patients’ cardiovascular and respiratory systems when conducting the nursing assessment process. When assessing the cardiovascular system, the nurse should assess heart sounds, S1, and S2. On the other hand, when assessing the respiratory system, the nurse should describe the chest walls, respiratory rhythm, and lung condition.
Additionally, when taking vital signs, information about the rate of PO2 under room air should be included in the objective data. Lastly, information about diagnostic tests and results should be included in the objective portion. Diagnostic tests can help a nurse make the appropriate decision when determining the disease ailing the patient. Without diagnostic tests and results, the nurse is likely to make an inaccurate diagnosis, and this can lead to medical errors.
Justification of the Assessment
Nurses should rely on subjective and objective data when deciding the health condition affecting the patient. The assessments for the case study include left lower quadrant pain and gastroenteritis. In my opinion, the charge nurse used the subjective data and some portion of the objective information to produce the assessment. Some of the symptoms of left lower quadrant pain include constipation, gas, diarrhea, indigestion, nausea, abdominal cramping or swelling, and blood in the stool (Dains et al., 2019). In the subjective data, the patient mentioned that she feels abdominal pain, diarrhea, and nausea. The nurse used the information to identify the first two diagnoses.
Physical examination of the abdomen can also be used to decide on the disease ailing the patient. The nurse assessed the abdomen and found that it is soft, has hyperactive bowel sounds, and pos pain was seen in the LLQ. However, the nurse should have also made the provided assessment basing their decision on the diagnostic test results for more accuracy. On the contrary, there were no diagnostic tests done on the patient, and hence my decision that part of the objective data was used to support the assessment.
Appropriate Diagnostic Tests for the Case and How they can be used to make Diagnosis
Three diagnostic tests can be ordered by the doctor to find the disease ailing the patient. The first test is the blood test. Colyar (2015) notes that a complete blood count (CBC) test can help identify an infection in a patient’s body. The result of the blood test will help in determining whether the patient in the case has an infection. The type of infection can be determined by performing a culture and sensitivity. Overall, blood test results will be used to determine whether the patient has an infection and the type of infection affecting the client. The second test is urinalysis.
This test is usually done to find whether infection or blood is present in the patient’s urinary tract (Ball et al., 2019). Urinary tract infection can pain in the uterus, kidneys, urethra, bladder, and as a result, lead to abdominal or back pain. Hence, the results of the test can be used to rule out UTI infection. The last test is a stool test. This test can be used to find blood in the stool. If the results show that the stool has blood that cannot be seen by naked eyes, then the patient has a problem with the upper digestive tract, a disease that can cause abdominal pain.
Diagnoses
I would accept the current diagnosis due to the following reasons. First, the patient noted that she has been feeling abdominal pain for three days. She also reported the feeling of nausea and diarrhea (Mian et al., 2018). All these symptoms are signs of left lower quadrant pain making the disease a possible diagnosis. Gastroenteritis symptoms include vomiting, watery diarrhea, stomach pain, headache, fever, cramping, and nausea (Patel & Kinsella, 2017). The patient reported diarrhea, stomach pain, abdominal pain, and nausea, and that is why I accepted the diagnosis.
Apart from the two diagnoses, the following are the other three diseases that can be included in the differential diagnosis. The first disease is right lower quadrant pain. Some of the symptoms of the disease include nausea and abdominal pain, which have been reported by the patient (Mian et al., 2018). The second diagnosis is inflammatory bowel disease. The symptoms of the disease include fatigue, diarrhea, abdominal pain, and blood in the stool (Sahami et al., 2017). The third diagnosis is urinary tract infection site not specified. This disease has been included in the diagnosis because it causes abdominal pain (Clouse, 2018).
Conclusion
The nurse could have included the review of systems, the patient’s race, and hobbies in the subjective portion. The diagnostic test results and general appearance should have been included in the objective portion. Apart from the two diagnoses, the patient might be suffering from UTI site not specified, inflammatory bowel disease, or right lower quadrant pain.
References
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.
Clouse, M. K. (2018). Evidence-driven Diagnosis and Treatment of Acute Urinary Tract Infections in Long-term Care. https://repository.belmont.edu/dnpscholarlyprojects/9/
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
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.
Mian, M., Khosa, F., Ali, I. T., McLaughlin, P., Klass, D., Chang, S., & Nicolaou, S. (2018). Faster magnetic resonance imaging in emergency room patients with right lower quadrant pain and suspected acute appendicitis. Polish journal of radiology, 83, e340. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6323540/
Patel, D. R., & Kinsella, E. (2017). Evaluation and management of lower back pain in young athletes. Translational pediatrics, 6(3), 225. doi: 10.21037/tp.2017.06.01
Sahami, S., Konté, K., Buskens, C. J., Tanis, P. J., Löwenberg, M., Ponsioen, C. J., … & D’Haens, G. R. (2017). Risk factors for proximal disease extension and colectomy in left-sided ulcerative colitis. United European gastroenterology journal, 5(4), 554-562. https://doi.org/10.1177%2F2050640616679552
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FAQs
What can cause severe abdominal pain?
Introduction
Abdominal pain is a common health issue that can range from mild discomfort to severe distress. When it becomes severe, it often indicates an underlying problem that requires medical attention. In this article, we will explore the various causes of severe abdominal pain, their symptoms, and possible treatment options.
Understanding Abdominal Pain
Abdominal pain is characterized by discomfort or pain felt in the area between the chest and the pelvis. It can originate from various organs and structures in the abdomen, making it challenging to pinpoint the exact cause without proper evaluation.
Common Causes of Severe Abdominal Pain
1. Gastrointestinal Issues
Disorders such as gastritis, gastroenteritis, and peptic ulcers can lead to severe abdominal pain. Gastritis is the inflammation of the stomach lining, while gastroenteritis involves inflammation of the stomach and intestines, often caused by infections. Peptic ulcers are open sores that form on the inner lining of the stomach or the upper part of the small intestine due to stomach acid erosion.
2. Appendicitis
Appendicitis is the inflammation of the appendix, a small pouch located in the lower right abdomen. If not treated promptly, it can lead to a burst appendix, which is a life-threatening condition.
3. Gallstones
Gallstones are hardened deposits that form in the gallbladder. When a gallstone blocks the bile duct, it can cause severe abdominal pain, known as biliary colic.
4. Kidney Stones
Kidney stones are solid crystals that form in the kidneys and can cause excruciating pain as they pass through the urinary tract.
5. Urinary Tract Infection
Infections in the urinary tract, such as cystitis or kidney infections, can lead to severe abdominal pain, particularly in the lower abdomen.
6. Ectopic Pregnancy
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, often in the fallopian tube. This condition can cause severe abdominal pain and requires immediate medical attention.
7. Gynecological Conditions
Certain gynecological conditions like ovarian cysts, endometriosis, and pelvic inflammatory disease can lead to severe abdominal pain in women.
8. Pancreatitis
Pancreatitis is the inflammation of the pancreas, which can cause severe pain in the upper abdomen.
9. Hernia
A hernia occurs when an organ or tissue pushes through a weak spot in the surrounding muscle or connective tissue, leading to abdominal pain.
10. Inflammatory Bowel Disease
Inflammatory bowel diseases like Crohn’s disease and ulcerative colitis can cause chronic inflammation and severe abdominal pain.
Less Common Causes of Severe Abdominal Pain
1. Spleen Issues
Problems with the spleen, such as rupture or enlargement, can cause severe abdominal pain.
2. Liver Conditions
Certain liver conditions, including hepatitis and liver abscess, can lead to abdominal pain.
3. Intestinal Obstruction
An intestinal obstruction occurs when the intestines are partially or completely blocked, causing severe abdominal pain.
4. Diverticulitis
Diverticulitis is the inflammation or infection of small pouches that can develop in the walls of the colon, leading to abdominal pain.
5. Peritonitis
Peritonitis is the inflammation of the peritoneum, the lining of the abdominal cavity, which can cause severe, generalized abdominal pain.
When to Seek Medical Attention
Severe abdominal pain should never be ignored, especially if it is accompanied by other symptoms like fever, vomiting, blood in the stool, or difficulty breathing. If the pain is sudden, intense, or persistent, it is essential to seek immediate medical attention.
Diagnostic Process
When evaluating severe abdominal pain, doctors may employ various diagnostic methods:
1. Medical History and Physical Examination
A detailed medical history and physical examination can provide crucial clues about the possible cause of the pain.
2. Blood Tests
Blood tests can help identify signs of infection, inflammation, or organ dysfunction.
3. Imaging Tests
Imaging tests such as ultrasound, CT scan, or MRI can provide detailed images of the abdominal organs and help detect abnormalities.
4. Endoscopy and Colonoscopy
Endoscopy and colonoscopy are procedures used to visualize the upper digestive tract and colon, respectively, to diagnose issues like ulcers, inflammation, or tumors.
5. Laparoscopy
Laparoscopy is a minimally invasive surgical procedure that allows direct visualization of the abdominal organs, helping in the diagnosis of certain conditions.
Treatment Options
The treatment of severe abdominal pain depends on the underlying cause. Some common treatment options include:
1. Medications
Medications may be prescribed to manage pain, control infections, or reduce inflammation.
2. Surgery
Surgical intervention may be necessary to treat conditions like appendicitis, gallstones, or hernias.
3. Lifestyle Changes
For certain conditions like gastrointestinal issues or kidney stones, lifestyle modifications may help prevent recurrence and manage symptoms.
Coping with Abdominal Pain
Coping with severe abdominal pain can be challenging, both physically and emotionally. Here are some tips to help cope with the discomfort:
- Rest: Allow your body to rest and recover.
- Hot Compress: Applying a hot compress to the affected area can provide some relief.
- Stay Hydrated: Drink plenty of fluids to prevent dehydration.
- Avoid Trigger Foods: If you have gastrointestinal issues, avoid foods that exacerbate the pain.
- Stress Management: Practice relaxation techniques to manage stress, which can aggravate pain.
Conclusion
Severe abdominal pain can be a distressing experience and may indicate an underlying medical condition. It is crucial to seek prompt medical attention when experiencing such pain to ensure timely diagnosis and appropriate treatment. Remember, everyone’s body is different, and the causes of abdominal pain can vary, so it’s essential to consult a healthcare professional for personalized advice.
FAQs
- Can stress cause severe abdominal pain? Stress can exacerbate certain gastrointestinal conditions, leading to abdominal discomfort. However, stress alone may not be the primary cause of severe abdominal pain.
- Is severe abdominal pain always an emergency? Severe abdominal pain can be a sign of a medical emergency, especially if it is sudden, persistent, or accompanied by other concerning symptoms. It is best to seek immediate medical attention in such cases.
- Can I treat severe abdominal pain at home? Mild abdominal pain can sometimes be managed at home with rest, hydration, and over-the-counter pain medications. However, if the pain is severe or worsening, it is essential to consult a healthcare professional.
- Can dietary changes help manage abdominal pain? Yes, dietary changes may help manage certain gastrointestinal issues that cause abdominal pain. Consulting a healthcare professional or a registered dietitian can provide personalized dietary recommendations.
- Are there alternative therapies for coping with abdominal pain? Some individuals find relief from abdominal pain through alternative therapies like acupuncture, yoga, or mindfulness practices. However, it’s essential to discuss these options with a healthcare provider before trying them.
Types of Stomach Pain in Females
Introduction
Stomach pain can be a common complaint among females and may arise due to various underlying factors. It is essential to understand the different types of stomach pain experienced by women to help identify potential causes and seek appropriate medical attention. In this article, we will explore fifteen types of stomach pain frequently reported by females, along with their possible causes and potential remedies.
1. Menstrual Cramps
One of the most common types of stomach pain experienced by females is menstrual cramps, also known as dysmenorrhea. These cramps occur during the menstrual cycle and are caused by the contraction of the uterus to expel its lining. Over-the-counter pain relievers, heat therapy, and lifestyle changes can help alleviate menstrual cramps.
1. Lifestyle Tips for Menstrual Cramps
- Regular exercise
- A balanced diet
- Stress management techniques
2. Ovulation Pain
Some females experience stomach pain during ovulation, which is known as mittelschmerz. This occurs when the ovary releases an egg, causing slight bleeding and irritation in the abdominal cavity. Over-the-counter pain medications and rest can help relieve ovulation pain.
3. Gastroenteritis
Gastroenteritis, commonly known as stomach flu, is caused by viral or bacterial infections in the digestive system. Symptoms include stomach pain, diarrhea, vomiting, and fever. Staying hydrated and getting plenty of rest are crucial in managing gastroenteritis.
3. Foods to Eat During Gastroenteritis
- Clear fluids (water, broth, electrolyte drinks)
- Bland foods (rice, bananas, applesauce)
- Boiled potatoes
4. Gastritis
Gastritis is the inflammation of the stomach lining and can be caused by various factors, including excessive alcohol consumption, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), and bacterial infections. Avoiding triggers like spicy foods, alcohol, and quitting smoking can help manage gastritis.
5. Gallstones
Gallstones are solid particles that form in the gallbladder and can cause intense abdominal pain. Females are more prone to gallstones due to hormonal factors. Treatment options may include medication, dietary changes, or surgery.
5. Risk Factors for Gallstones
- Female gender
- Obesity
- Rapid weight loss
6. Appendicitis
Appendicitis is the inflammation of the appendix and requires immediate medical attention. Symptoms include severe abdominal pain, fever, and vomiting. Surgery is typically required to remove the inflamed appendix.
7. Urinary Tract Infection
Urinary tract infections (UTIs) can cause lower abdominal pain in females. They are usually caused by bacteria entering the urinary tract. Antibiotics are commonly prescribed to treat UTIs.
7. Preventive Measures for UTIs
- Staying hydrated
- Urinating before and after intercourse
- Wearing breathable underwear
8. Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder that can lead to abdominal pain, bloating, and changes in bowel habits. Managing stress and dietary modifications can help alleviate IBS symptoms.
9. Endometriosis
Endometriosis is a condition in which the tissue that lines the uterus grows outside of it. This can cause severe abdominal pain, especially during menstruation. Treatment options may include pain medication, hormone therapy, or surgery.
10. Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized egg implants itself outside the uterus, most commonly in the fallopian tubes. It can lead to severe abdominal pain and requires immediate medical attention.
11. Ovarian Cysts
Ovarian cysts are fluid-filled sacs that develop on the ovaries. They can cause mild to severe abdominal pain and may resolve on their own or require medical intervention.
12. Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is an infection of the female reproductive organs, often caused by sexually transmitted infections (STIs). It can cause abdominal pain, fever, and vaginal discharge. Antibiotics are usually prescribed to treat PID.
13. Uterine Fibroids
Uterine fibroids are non-cancerous growths that develop in the uterus. They can cause abdominal pain and heavy menstrual bleeding. Treatment options include medication, hormonal therapy, or surgery.
14. Ovarian Cancer
Though rare, ovarian cancer can cause abdominal pain, bloating, and other digestive issues. Early detection is crucial for better treatment outcomes.
15. Peptic Ulcers
Peptic ulcers are open sores that develop on the inner lining of the stomach or the upper part of the small intestine. They can cause stomach pain and discomfort, and treatment may involve medication and lifestyle changes.
Conclusion
Understanding the various types of stomach pain experienced by females is essential for early identification, proper management, and timely medical intervention. If you or someone you know experiences persistent or severe abdominal pain, it is crucial to seek medical attention promptly.
FAQs
1. Can menstrual cramps be relieved without medication?
Yes, menstrual cramps can be alleviated through lifestyle changes, such as regular exercise and stress management techniques.
2. How can I prevent urinary tract infections?
Staying hydrated, urinating before and after intercourse, and wearing breathable underwear can help reduce the risk of urinary tract infections.
3. Are ovarian cysts always harmful?
Not all ovarian cysts are harmful; some may resolve on their own without requiring medical intervention.
4. What are the risk factors for gallstones?
Female gender, obesity, and rapid weight loss are some of the risk factors for gallstones.
5. Is pelvic inflammatory disease (PID) only caused by STIs?
PID can be caused by sexually transmitted infections (STIs), but it can also result from other types of infections.
