Analyze the objective portion of the note

Reference no: EM133480543

Homework: Abdominal Aortic Aneurysm Case Study

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 Homework, 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

Review the Episodic note case study your instructor provides you for this Homework. See the "Course Announcements" section of the classroom for your Episodic note case study.

With regard to the Episodic note case study provided:

Question 1) Review this Learning Resources, and consider the insights they provide about the case study.

Question 2) Consider what history would be necessary to collect from the patient in the case study.

Question 3) 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?

Question 4) Identify at least five possible conditions that may be considered in a differential diagnosis for the patient

Question 5) The Homework(In the past some students have listed each question that needs to be answered and then wrote there narrative under each question). This is easier for some students.

Question 6) Analyze the subjective portion of the note. List additional information that should be included in the documentation.

Question 7) Analyze the objective portion of the note. List additional information that should be included in the documentation.

Question 8) Is the assessment supported by the subjective and objective information? Why or why not?

Question 9) What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?

Question 10) 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.

Homework The causes of abdominal pain can be extremely varied due to the sheer number of structures, organs, and functions within the abdomen. If abdominal pain is caused by a life-threatening condition, then swift and accurate assessment is essential.In preparation for the Comprehensive (Head-to-Toe) Physical Assessment, it is recommended that you practice performing an abdominal examination. The abdominal concept lab is required but everything else is for practice.

I. ABDOMINAL ASSESSMENT

II. Abdominal Assessment

III. Subjective:

IV. CC: "My stomach has been hurting for the past two days."

V. 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.

VI. 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

Reference no: EM133480543

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