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Week 6 _ Assignment 1: Lab Assignment: Assessing the Abdomen

Ariel Cordova Lopez

Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Dr. Tiffany Benefield

October 9, 2021

Subjective Portion

Patient information is essential when providing care to a patient. In the case of abdominal pain, it requires that subjective data on the patient is collected. This in- cludes the patient’s subjective history information to narrow down on the possible diagnosis. The Chief Complain is that the “stomach hurts, I have a diarrhea.” The HPI includes the timing and onset of the abdominal pain, which started three days ago. The HPI also includes the characteristics of abdominal pain, and the practi- tioner must collect more information on the present condition and history by asking focused questions. In addition, the teh health practitioner should include infor- mation on the patient’s diet and the history before the start of the abdominal pains. In this scenario, the practitioner should include more information on the patient’s history, the patient’s general health, and the current condition in the SOAP note (Podder, et al 2020). As it relates to abdominal pain, the history of the current ill-

ness should include information such as start, duration, features, exacerbating, and relieving symptoms. One of the most important questions to ask before the

first exam is the specific location where the patient is experiencing the pain. The patient also reports on stopping his medication, and the healthcare provider must ask the reason for each medication and the reason for stopping. Lastly, the history information must be collected and included in the assessment and patient’s life- style and exercise as they are good practices for diabetes and hypertension. Information on the amount of alcohol the patient consumes should also be included in the history. Objective Portion

In the SOAP, information on the general appearance of the patient should be added. This includes whether the patients answer all the questions appropriately,

their posture, mood, and maintaining good hygiene. The practitioner should indicate the results of the percussion of the abdomen. The general assessment and infor- mation on HEENT are entirely missing. The information in this case study for the vital signs would include information on General, Skin, Chest, Abdomen, and

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Genitourinary. These areas contain all the organs that may be the cause of abdominal pain. There were two positive findings in which this practitioner needed to

use palpation and a stethoscope. The negative results for the rest of the examination need documentation for palpation and auscultation. Lastly, if JR has a history of GI bleed, where is the CBC, skin pallor, and cap refill? If JR is a diabetic with diarrhea, where is his blood glucose and CMP? What is the character of LLQ palpation find- ings? Mass/no mass. Rebound tenderness? It is essential information on the patient’s CBC, WBC, CMP, and Abdominal X-ray. Objective and subjective data

partially support the assessment. For example, the patient’s primary complaint, which includes stomach pain, diarrhea, and nausea, supports the Gastroenteritis

diagnosis. Gastroenteritis symptoms include stomach pain, watery diarrhea, fever, nausea, cramps, and headache (Bányai, et al., 2018). The personal informa-

tion provided by the patient supported the diagnosis of gastroenteritis; however, the objective part of the SOAP note was not incorporated in the evaluation when coming up with the diagnosis. The patient complained of generalized pain, but the assessment indicates left lower quadrant pain indicated in the objective data;

hence, further investigation is needed as a severe medical condition could disguise as GI symptoms.

Diagnostic tests Stool Occult Test-The test is crucial because it determines whether or not there is blood in the stool. Not a usual outcome. If blood in

the stool cannot be seen with the unaided eye, it indicates a severe problem in the upper digestive tract. Blood Test –CBC and CMP tests can indicate whether there is an infection in the patient’s body. Liver function test-are tests carried out to determine the functioning of the liver. The liver plays a significant role in getting rid

of toxins in the body. If the liver is not properly functioning, it may lead to abdominal pains. Since the patient has frequent diarrhea, the CMP would reveal the

current health condition of the kidneys, liver, and electrolytes. Abdomen CT and X-ray- The kidneys, ureters, bladder, intestines, and pelvic and spinal bones are exam- ined on an abdomen X-ray. This test is highly beneficial for evaluating if the patient’s pain is caused by gas in the gastrointestinal system or diarrhea or if the patient has kidney stones causing pain. The objective data indicates the presence of left lower quadrant pain, while the subjective data indicates gastroenteritis, as the patient has a fever, diarrhea, and abdominal pain. Hence I will reject the diagnosis as it does not take into consideration of the objective data.

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Differential Diagnosis

Diverticulitis

This is the inflammation or infection of the diverticula. Diverticula, also known as colonic diverticula, are small pouches or sacs that develop in weak spots in the

large intestine (colon) with symptoms such as left lower abdomen pain, fever, nausea, vomiting, and abdominal discomfort. Because it contains both subjective

and objective data, this is most certainly my preferred diagnosis. Intestinal obstruction

It occurs when food cannot flow through the large or small intestines. Abdominal pains, stomach cramps, vomiting, constipation, and nausea are all symp-

toms of intestinal obstruction (Mayo Foundation for Medical Education and Research. (2015) Gallstones

Gallstones are due to gallbladder blockage is caused by solid materials forming in the gallbladder, and symptoms include nausea, vomiting, indigestion, and stomach pain (Gutt, et al., 2020). H. Pylori

This is a bacterial infection of the stomach that presents vomiting, nausea, and bloating symptoms. Ulcerative colitis

This is an inflammatory bowel disease that causes inflammation and ulcers in the digestive tract. The symptoms of the disease include diarrhea, abdominal

pain, weight loss, fatigue, and fever.

References

Bányai, K., Estes, M. K., Martella, V., & Parashar, U. D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175-186. Gutt, C., Schläfer, S., & Lammert, F.

(2020). The treatment of gallstone disease. Deutsches Ärzteblatt International, 117(9), 148. Mayo Foundation for Medical Education and Research. (2015,

December 31). Intestinal obstruction Symptoms and causes – Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/intestinal- obstruction/symptoms-causes/dxc-20168463

Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP notes. StatPearls [Internet]. Thompson, G., & Elvir, R. (2020). Abdominal Pain of Unknown Origin. Tsay, F.

W., & Hsu, P. I. (2018). H. pylori infection and extra-gastroduodenal diseases. Journal of biomedical science, 25(1), 1-8.

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Week 6 _ Assignment 1:

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WEEK 6 ASSIGNMENT 1

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Assessing the Abdomen

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Assessing the Abdomen

 

 

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Advanced Health Assessment and Diagnostic Reasoning

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Advanced Health Assessment and Diagnostic Reasoning

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As it relates to abdominal pain, the history of the current illness should include informa- tion such as start, duration, features, exacerbating, and relieving symptoms.

Original source

The present illness history should include information such as, onset, duration, character- istics, exacerbating, and alleviating symptoms as it relates to abdominal pain

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One of the most important questions to ask before the first exam is the specific location where the patient is experiencing the pain.

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The location is one of the most important questions to ask before the first exam (Ball,2015)

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In the SOAP, information on the general appearance of the patient should be added.

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•information on the general appearance of the patient

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The information in this case study for the vital signs would include information on General, Skin, Chest, Abdomen, and Genitourinary.

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The soap note for the case study would be vital signs, general, skin, chest, abdomen, and genitourinary (Ball et al, 2019)

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These areas contain all the organs that may be the cause of abdominal pain. There were two positive findings in which this practitioner needed to use palpation and a stetho- scope. The negative results for the rest of the examination need documentation for pal- pation and auscultation. Lastly, if JR has a history of GI bleed, where is the CBC, skin pal- lor, and cap refill?

Original source

These areas contain all the organs that may be the cause of abdominal pain There were two positive findings in which this practitioner needed to use palpation and a stetho- scope The negative results for the rest of the examination need documentation for palpa- tion and auscultation Lastly, if JR has a history of GI bleed, where is the CBC, skin pallor, cap refill

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If JR is a diabetic with diarrhea, where is his blood glucose and CMP? What is the charac- ter of LLQ palpation findings?

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If JR is a diabetic with diarrhea, where is his blood glucose and CMP What is the character of LLQ palpation findings

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Mass/no mass.

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Mass/no mass

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Objective and subjective data partially support the assessment.

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The subjective and objective data partially support the assessment

 

 

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For example, the patient’s primary complaint, which includes stomach pain, diarrhea, and nausea, supports the Gastroenteritis diagnosis.

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The patient’s chief symptom of stomach pain, diarrhea, and nausea supports the diagno- sis of gastroenteritis

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Gastroenteritis symptoms include stomach pain, watery diarrhea, fever, nausea, cramps, and headache (Bányai, et al., 2018).

Original source

According to Martin (2016), gastroenteritis symptoms include stomach pain, watery diar- rhea, fever, nausea, cramping, and headache

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The patient complained of generalized pain, but the assessment indicates left lower quadrant pain indicated in the objective data;

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The patient complained of generalized pain that is entirely different from the pain of the left lower quadrant (LLQ) obtained in the Objective data

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Diagnostic tests Stool Occult Test-The test is crucial because it determines whether or not there is blood in the stool.

Original source

Stool occult test- The test is done to confirm if there is blood in the stool or not

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Not a usual outcome.

Original source

That is not a usual outcome

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If blood in the stool cannot be seen with the unaided eye, it indicates a severe problem in the upper digestive tract.

Original source

If blood in the stool that the eye cannot see, it would indicate a severe upper digestive tract issue

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Liver function test-are tests carried out to determine the functioning of the liver.

Original source

· Liver function test – as the name suggests, liver function tests are carried out to deter- mine the functioning of the liver

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Since the patient has frequent diarrhea, the CMP would reveal the current health condi- tion of the kidneys, liver, and electrolytes.

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The CMP would give a present health status of the kidneys, liver and electrolytes since the patient complains of frequent diarrhea

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This is the inflammation or infection of the diverticula.

Original source

Diverticulitis is an infection or inflammation of the diverticula

 

 

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Because it contains both subjective and objective data, this is most certainly my preferred diagnosis.

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Because it contains both subjective and objective data, this is most certainly my preferred diagnosis

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It occurs when food cannot flow through the large or small intestines.

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When food is unable to travel through the large or small intestines, this occurs

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Abdominal pains, stomach cramps, vomiting, constipation, and nausea are all symptoms of intestinal obstruction (Mayo Foundation for Medical Education and Research.

Original source

According to the Mayo Foundation of Medical Education and Research (2015), the symp- toms of intestinal obstruction include abdominal pains, stomach cramps, vomiting, con- stipation, and nausea

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This is an inflammatory bowel disease that causes inflammation and ulcers in the diges- tive tract.

Original source

Ulcerative colitis is an inflammatory bowel disease causing inflammation and ulcers in the digestive tract

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The symptoms of the disease include diarrhea, abdominal pain, weight loss, fatigue, and fever.

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The symptoms of this disease include diarrhea, abdominal pain, weight loss, fever, and loss of appetite (Olivier et al., 2020)

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Bányai, K., Estes, M. K., Martella, V., & Parashar, U.

Original source

Bányai, K., Estes, M K., Martella, V., & Parashar, U

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The Lancet, 392(10142), 175-186.

Original source

Lancet, 392(10142), 175–186

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Mayo Foundation for Medical Education and Research. (2015, December 31). Intestinal obstruction Symptoms and causes – Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms- causes/dxc-20168463

Original source

Mayo Foundation for Medical Education and Research (2015, December 31) Intestinal ob- struction Symptoms and causes – Mayo Clinic Retrieved from http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/ dxc-20168463

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Podder, V., Lew, V., & Ghassemzadeh, S.

Original source

Podder V, Lew V, Ghassemzadeh, S

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