The Episodic Note Case Study: Abdominal Assessment

Subjective Portion

One primary subjective data that must be included is the review of the systems (ROS).
These are patient responses about symptoms related to body systems, including musculoskeletal,
urinary, GIT, neurological, respiratory, integumentary, and cardiac (Wilson & Giddens, 2021).
Secondly, a “self-reported” pain scale can be used to subjectively assess the patient’s pain level.
Self-reported scales may include the numeri rating scale, verbal descriptor scale, pain
thermometer, visual analog scale, or the pictorial pain scale. Another area that should be included
is the mental health assessment. Ask the patient to describe thoughts, feelings, and emotions.
Most importantly, information about his spiritual and cultural beliefs can be collected to
understand their medical preferences and attitudes toward healthcare.

Objective Portion

Laboratory and imaging results must be included to assist in making the correct
diagnosis. This includes results of the computed tomography angiography, ultrasound, liver
function tests, and complete blood count (CBC). Also, expand the physical review of the body
systems. There should be a more detailed analysis of the relevant areas affected by the disease.
For example, provide comprehensive results of blood and metabolic tests, such as bowel sound
changes, and lipase/serum levels. Additionally, quantify the patient’s pain level using
observational pain scales rather than self-reported scales. Potential observational pain scales to
use include the Abbey pain scale, the Pain Assessment in Advanced Dementia, or the Pain
Assessment Checklist (Victoria Department of Health, n.d.). These scales are appropriated
considering the patient is older (65 years).

Assessment Supported

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The assessment (pancreatis, perforated ulcer, and abdominal aortic aneurism) is
indubitably supported by both subjective and objective data.

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

Diagnostic Tests

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

Rejection or Acceptance

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
Possible Conditions

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References

Victoria Department of Health. (n.d.). Identifying pain. https://www.health.vic.gov.au/patient-
care/identifying-pain
Wilson, S. F., & Giddens, J. F. (2021). Student Laboratory Manual for Health Assessment for
Nursing Practice – E-book. Elsevier Health Sciences.