Abdominal Assessment
A 65-year-old African American presents to the emergency department with a two days history of intermittent epigastric abdominal pain radiating from the back. Following an assessment, he was diagnosed with abdominal aortic aneurysm (AAA) but the doctor ordered a CTA scan. However, diagnosis of abdominal pain is a time-consuming and challenging process that can result in misdiagnosis if not conducted properly. The doctors recommendation of a CTA scan is geared towards ensuring a proper diagnosis of the patients condition. In addition to the recommended CTA scan, it is critical to review the patients history, physical exams, and diagnostic tests. This paper examines the patients abdominal assessment presented in the Episodic note case study in order to formulate a differential diagnosis of his condition.
Current Assessment
The Episodic note case study provides subjective and objective data collected from the patient that resulted in the AAA diagnosis. The current assessment is supported by the subjective and objective information presented in the case study. Prior to conducting any diagnostic tests, the healthcare provider obtained information relating to the history of present illness, past medical history, family history, and social history. Insights obtained from the subjective data was used as the premise for conducting the physical exam in order to obtain objective information. The use of subjective data to guide the physical exam demonstrates that the current assessment is supported by subjective and objective information.
However, the healthcare practitioner should have obtained additional information about the patients condition. The collection of subjective data should have included a review of systems/symptoms, particularly those relating to the location of the pain. According to Cartwright & Knudson (2008), the location of pain has significant predictive value when collecting subjective data on abdominal pain. When collecting information on the history of present illness, the physician should have considered conditions of the abdominal wall. Information on aggravating and alleviating factors would also be necessary to obtain from the patient. In addition, surgical history and history of hospitalizations...
…serious condition in which a tear occurs in the aorta (Cartwright & Knudson, 2008). The patient could be diagnosed with this condition because of the severe epigastric pain that radiates to the back and smoking history. Bowel obstruction is the other differential diagnosis that could be applicable to the patient because of severe epigastric pain, epigastric tenderness, and vomiting (Macaluso & McNamara, 2012).In conclusion, this scenario demonstrates some of the complexities physicians face in the assessment and diagnosis of abdominal pain. The complexity is partly attributable to the fact that abdominal pain is one of the most common reasons for visits to the emergency department. As evident in the case study, proper diagnosis of abdominal pain requires a comprehensive assessment of a patients history and presenting symptoms. Insights obtained from subjective data should be utilized to guide the physical examination of a patient. However, physicians should conduct a detailed review of subjective and objective information in order to use the appropriate diagnostic tests for a patients condition.…
References
Cartwright, S.L. & Knudson, M.P. (2008). Evaluation of acute abdominal pain in adults. American Family Physician, 77(7), 971-978.
Macaluso, C.R. & McNamara, R.M. (2012). Evaluation and management of acute abdominal pain in the emergency department. International Journal of General Medicine, 5, 789-797.
Mehta, H. (2016). Abdominal pain. Clinical Pathways in Emergency Medicine, 1, 329-345. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7121692/
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