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1
ABDOMINAL ASSESSMENT
Note – there is no need to make up any information for the case study. You are to review
what is provided below and formulate an essay response in terms of what is needed for
a SOAP Note with rationale. To be successful, I encourage you to analyze using the
SOAP Note Template and my feedback. For example, does the HPI capture all aspects of
the mnemonic? Are all allergies indicated?
CASE STUDY
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 him 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:
1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis
2
TO PREPARE
Review the Episodic note case study your instructor provides you for this week’s
Assignment. With regard to the Episodic note case study provided:
o
o
o
o
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
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. Make sure to include both the school and
outside resources.
3
LEARNING RESOURCES
Required Readings
•
•
•
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2023). Seidel’s guide to physical examination: An interprofessional
approach (10th ed.). St. Louis, MO: Elsevier Mosby.
o 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.
o Chapter 3, “Abdominal Pain Download 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.
o Chapter 10, “Constipation”Download 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.
o Chapter 12, “Diarrhea”Download 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.
o Chapter 29, “Rectal Pain, Itching, and Bleeding”Download 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.
o Chapter 115, “X-Ray Interpretation of Abdomen” Download “X-Ray
Interpretation of Abdomen”(pp. 514–520)
4
Note: Download this Student Checklist and Abdomen Key Points to
use during your practice abdominal examination.
•
Document: Midterm Exam Review Download Midterm Exam Review(Word
document)
Required Media
Assessment of the Abdomen and Gastrointestinal System – Week 6 (14m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the
course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations
in Chapter 17 that relate to the assessment of the abdomen and gastrointestinal system.
Refer to Week 4 for access instructions on https://evolve.elsevier.com/Links to an
external site.
Optional Resources
•
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic
examination (11th ed.). New York, NY: McGraw Hill Medical.
Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”
This chapter explores the health assessment processes for the
abdomen, perineum, anus, and rectosigmoid. This chapter also
examines the symptoms of many conditions in these areas.
o Chapter 10, “The Urinary System”
In this chapter, the authors provide an overview of the physiology
of the urinary system. The chapter also lists symptoms and
conditions of the urinary system.
Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V.
(2021). Changing paradigms in the management of acute uncomplicated
diverticulitisLinks to an external site.. Scandinavian Journal of Surgery, 110(2),
180–186. https://doi.org/10.1177/14574969211011032
Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain
in the elderly patient: Point-of-care ultrasound diagnosis of small bowel
obstructionLinks to an external site.. Clinical Practice and Cases in Emergency
Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029
o
•
•
1
ABDOMINAL ASSESSMENT
Note – there is no need to make up any information for the case study. You are to review
what is provided below and formulate an essay response in terms of what is needed for
a SOAP Note with rationale. To be successful, I encourage you to analyze using the
SOAP Note Template and my feedback. For example, does the HPI capture all aspects of
the mnemonic? Are all allergies indicated?
CASE STUDY
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 him 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:
1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis
2
TO PREPARE
Review the Episodic note case study your instructor provides you for this week’s
Assignment. With regard to the Episodic note case study provided:
o
o
o
o
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
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. Make sure to include both the school and
outside resources. Please use APA format with subheadings to clarify which part
of the question is being answered.
3
LEARNING RESOURCES
Required Readings
•
•
•
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2023). Seidel’s guide to physical examination: An interprofessional
approach (10th ed.). St. Louis, MO: Elsevier Mosby.
o 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.
o Chapter 3, “Abdominal Pain Download 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.
o Chapter 10, “Constipation”Download 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.
o Chapter 12, “Diarrhea”Download 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.
o Chapter 29, “Rectal Pain, Itching, and Bleeding”Download 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.
4
o
Chapter 115, “X-Ray Interpretation of Abdomen” Download “X-Ray
Interpretation of Abdomen”(pp. 514–520)
Note: Download this Student Checklist and Abdomen Key Points to
use during your practice abdominal examination.
•
Document: Midterm Exam Review Download Midterm Exam Review(Word
document)
Required Media
Assessment of the Abdomen and Gastrointestinal System – Week 6 (14m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the
course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations
in Chapter 17 that relate to the assessment of the abdomen and gastrointestinal system.
Refer to Week 4 for access instructions on https://evolve.elsevier.com/Links to an
external site.
Optional Resources
•
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic
examination (11th ed.). New York, NY: McGraw Hill Medical.
Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid”
This chapter explores the health assessment processes for the
abdomen, perineum, anus, and rectosigmoid. This chapter also
examines the symptoms of many conditions in these areas.
o Chapter 10, “The Urinary System”
In this chapter, the authors provide an overview of the physiology
of the urinary system. The chapter also lists symptoms and
conditions of the urinary system.
Chabok, A., Thorisson, A., Nikberg, M., Schultz, J. K., & Sallinen, V.
(2021). Changing paradigms in the management of acute uncomplicated
diverticulitisLinks to an external site.. Scandinavian Journal of Surgery, 110(2),
180–186. https://doi.org/10.1177/14574969211011032
Hussein, A., Arena, A., Yu, C., Cirilli, A., & Kurkowski, E. (2021). Abdominal pain
in the elderly patient: Point-of-care ultrasound diagnosis of small bowel
obstructionLinks to an external site.. Clinical Practice and Cases in Emergency
Medicine, 5(1), 127–128. https://doi.org/10.5811/cpcem.2020.11.50029
o
•
•
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