Posted: November 6th, 2022
Advanced Health Assessment.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?Advanced Health Assessment.
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What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
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.Advanced Health Assessment.
Additional Subjective Data
It is essential to include more details on the nature of the abdominal pain with reference to where the pain radiates to, originates from, nature of its onset, aggravating and relieving factors. Gastroenteritis usually begins as an acute infectious condition with a sudden onset (Jansen, et al., 2015). The onset of the patient’s diarrhea should also be stated including the color, episodes in a day, if its mucoid, bloody or watery. Gastroenteritis can occur due to a parasitic, viral or bacterial infection. Bacterial infections usually cause a bloody diarrhea and viral infections cause watery diarrhea (Oude & Van der Hoek, 2016). By obtaining more details regarding the nature of the stool, it will be possible to make a more specific diagnosis that would guide management.
It will also be necessary to know and document how the patient tolerates liquid and solid foods, her procedure of obtaining groceries and method of preparation. As highlighted by Jansen, et al. (2015), gastroenteritis often occurs from ingestion of contaminated food or water or inadequately prepared using the required sanitation protocols. The patient’s history of travel must be documented since the risk of gastroenteritis increases when travelling when exposed to infectious agents. Associated symptoms such as vomiting, bloating and burning should also be established.Advanced Health Assessment.
Additional Objective Data
It will be necessary to include details about the patient’s possible exposure to infectious conditions and the characteristics of the stool that was obtained for examination. Details on the condition of the abdomen in terms of the skin color, symmetry and contours on inspection should be included. Information on any masses felt on palpation, pulsations, veins and scars should also be included. The frequency and character of the bowel sounds, bruits in the femoral, iliac and aortic places on auscultation should also be highlighted. According to Kendall & Moreira (2017), bruits are indicative of a possible obstruction, gastroenteritis or peritonitis. Documentation of abnormal findings such as ascites, distention or organ enlargement on percussion should also be done. In case any mass is felt, documentation should include its shape, mobility, location and size.Advanced Health Assessment.
A comparison with the normal findings should be made whereby: the abdomen is round, soft and symmetric without any visible peristalsis, distention, lesions and scars. The aorta should be medially located without any visible peristalsis or bruits, the umbilicus should be inverted, medial and without herniation (Kendall & Moreira, 2017). While bowel sounds should be present in all four quadrants, the spleen, liver and kidney should be non-tender and non-palpable.Advanced Health Assessment.
How the Subjective and Objective Data Support the Assessment
Based on the client’s assessment, she had gastroenteritis and pain on the left lower quadrant. The subjective data provided by the client revealed that she experienced severe abdominal pain for three days and diarrhea. Objective data revealed that the client had a low grade fever of 99.8 and hyperactive bowel sounds, symptoms that are often accompanied with lack of energy and dehydration due to frequent diarrhea and vomiting in patients with gastroenteritis.Advanced Health Assessment.
Appropriate Diagnostic Tests
The most appropriate test for this patient to make a diagnosis is a stool test alongside a comprehensive medical history. To make a more definite diagnosis, the signs and symptoms reported by the client should be compared against gastroenteritis actual signs and symptoms. According to Lacy et al. (2016), a stool test will help to determine if the client has a parasitic, bacterial or viral infection. Watery stool will suggest a viral infection while bloody stool will suggest bacterial gastroenteritis.
Whether I Would Accept/Reject the Current Diagnosis
The patient’s current diagnosis is gastroenteritis whose signs and symptoms are: dehydration, abdominal pain, vomiting, fever and diarrhea which begin 12-72 hours immediately one gets into contact with an infectious agent, symptoms that last for less than two weeks (Scallan et al., 2018). The frequent diarrhea due to hyperactive bowel sounds cause abdominal pain, findings which are consistent with the patient’s presentation, the objective and subjective data provided. Thus, I would accept the present diagnosis.Advanced Health Assessment.
Possible Differential Diagnoses
UTI (Urinary Tract Infection)
IBD (Inflammatory Bowel Disease)
Week 6: Assessment of the Abdomen and Gastrointestinal System
• CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
• HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
• PMH: HTN, Diabetes, hx of GI bleed 4 years ago • Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
• Allergies: NKDA
• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
• Heart: RRR, no murmurs • Lungs: CTA, chest wall symmetrical
• Skin: Intact without lesions, no urticaria
• Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
• Diagnostics: None Assessment: • Left lower quadrant pain
• Gastroenteritis PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses
Advanced Health Assessment.
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