The subjective portion of the note consists of the following information: the patient is a woman currently complaining of severe abdominal cramping. Significant information that should be included in the subjective note include when did the pain begin? How did it begin; was it gradual or sudden? What is the progress of the pain; is it becoming worse or better? (Dains et al., 2019). What is its character; is it a dull pain, sharp, burning, stabbing or stinging pain? Is the pain radiating or non-radiating? If it is the radiating type, where does it radiate from and to where?
Are there any other symptoms associated with the pain, such as nausea and vomiting? What relieves the pain; does medication, lying in a certain position or sitting in a particular posture alleviate the pain? What increases the pain; does standing, walking or sitting in a certain way augment the pain? What is the timing of the pain? Is it continuous or discontinuous, does the pain come more often during particular times of the day? Does the pain interfere with daily activities such as work, in such a manner that she is unable to continue with her duties?
The objective portion of the note consists of this information: while she had been diagnosed with diverticulitis, a CT scan revealed pancreatic growth that turned out to be pancreatic cancer. Additional information that would be significant should include whether the patient was treated of similar symptoms. In case the response is positive, the nurse should seek information as to what tests were conducted on the patient and what the diagnosis was at the time. Also, the care management approach used in her case would be helpful.
A focused adnominal history would assist in minimizing chances of misdiagnosis. The questions relevant would be how long ago did the pain start? Was the onset gradual or sudden and how severe was the pain on a scale of 1 to 10? Does the pain prevent the patient from engaging in daily tasks/responsibilities? Does she awake from sleep due to the pain? It is also important to know what has been the course of the pain since it started. Is it getting worse or better? When was the last bowel movement? Has she ever had the pain before; if so what was diagnosed, how was it treated?
The focused physical examination will commence with noting the general appearance. Visceral pain often makes patients restless and uncomfortable. An assessment of the vital signs is also mandatory (Dains et al., 2019). The nurse should check out for shallow respirations, tachypnea or tachycardia. Documented weight loss should be noted since the patient has a neoplasm. The nurse should observe the abdominal musculature for features of rigidity, the coloring of the abdominal skin and note any abdominal distention. An auscultation for bowel sounds, percussion for tones and guarding and palpation for masses will also assist in forming a definitive diagnosis for this patient. For this patient, the differential diagnoses include diverticulitis, hernia, costochondritis, Crohn disease, irritable bowel syndrome, esophagitis, uterine fibroids, dysmenorrhea or recurrent UTI.
The assessment is supported by the subjective and objective information. Since the patient complains of chronic pain, conditions presenting with acute pain such as pancreatitis, appendicitis, peritonitis and intestinal obstruction are unlikely. The nurse may rule out these conditions from the differential diagnosis. Also, symptoms such as diarrhea and vomiting may be present in Crohn disease and irritable bowel syndrome. Therefore, their absence may drive the care provider to other conditions. Signs such as tachycardia, tachypnea and shallow breathing if present may indicate presence of metabolic acidosis, where the patient tries to compensate using the respiratory system (LeBlond et al., 2014).
Shallow breathing may further indicate airway obstruction by another underlying illness like pneumonia. Absent bowel sounds are indicative of conditions such as paralytic ileus or partial or total duodenectomy, ileectomy or jejunectomy. Palpation will reveal presence of underlying intraabdominal masses (Ball et al., 2019). In this patient, the growth noted on the pancreas is likely to be palpable. Percussion of the abdomen for this case may not yield positive results unless the spleen and the liver are enlarged. In hepatosplenomegaly, a dull note on percussion may be elicited. Percussion will yield a tympanic note also owing to absence of ascetic fluid in the patient.
Several diagnostic tests will be relevant for this patient. Serum lipase levels should be tested. Serum lipase levels are elevated in pancreatic tumors, and the test is more specific than serum amylase levels.
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