Posted: January 5th, 2023
Assessing the Abdomen Essay
In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Abdominal Assessment SUBJECTIVE: 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. Assessing the Abdomen Essay. 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) OBJECTIVE: 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, hyperctive 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. To prepare: With regard to the SOAP note case study provided: Review this week’s Learning Resources, and consider the insights they provide about the case study. Consider what history would be necessary to collect from the patient in the case study. Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Assessing the Abdomen Essay. How would the results be used to make a diagnosis? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. To complete: 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? 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 3 different references from current evidence based literature. Assessing the Abdomen Essay
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Assessing the Abdomen
Additional Subjective Portion of the Note
Any changes in appetite or food intake should have been noted. This is because the loss of appetite can help in arriving into the diagnosis. The types of food that the patient is eating should be noted because there are some foods that can aggravate the pain or cause a flare-up of the pain(Rached& Haji, 2016). Intolerance to a certain food should also be noted because food intolerance can point to issues like gastrointestinal imbalance like having inadequate enzymes to breakdown foods or point to disorderslikeinsulin-dependent diabetes or inflammatory bowel disease. Some of the food intolerance symptoms may consist of gas, diarrhea, bloating, constipation, abdominal pain etc. Any change in bowel movement should also be noted (Rached& Haji, 2016).
Additional Objective Portion of the Note
For the objective data, the bowel movement should be recorded such as the amount, consistency, color and frequency of the bowel movement. The precise pain scale should also be noted. In addition, the patient’s intake and output should also be documented because accurate input and output are important for suitable clinical decision-making(Rached& Haji, 2016). Assessing the Abdomen Essay
Support of the Assessment by the Subjective and Objective Information
The assessment is not supported by the current subjective and objective information because additional information is needed to complete a proper assessment. Moreover, diagnostic testing is necessary in order to rule out any other likely diagnosis. For example, in the assessment, the exact location of the abdominal pain is not indicated and the pain has also not been described for example if the pain is shooting, sharp, throbbing, cramping or stabbing so classifying the pain as referred, visceral or parietal is not possible(Rached& Haji, 2016). In addition, it is not indicated if there are foods that aggravate pain or the duration of the pain after it starts. Finally, alleviating factors of the pain such as defecating or belching should be indicated(Rached& Haji, 2016). Assessing the Abdomen Essay
Appropriate Diagnostic Tests
A laboratory test such as stool culture or stool microscopy can be performed for the patient’s stool in order to identify the exact microorganism that is causing the gastroenteritis. A radiologic examination can be done to rule out the probability of inflammatory bowel disease.
Reject/Accept the Current Diagnosis
The current diagnosis of gastroenteritis is not acceptable. This is because even if the patient is manifesting some of symptoms and findings in gastroenteritis, the provided information cannot confirm the diagnosis because it is inadequate and also because no diagnostic test has been done to confirm the diagnosis (Humphries&Linscott, 2015). Additionally, there are various differential diagnoses that can be derived from the provided information. Some of the diagnoses include food poisoning, Clostridiumdifficile colitis, and protozoal infection. Food poisoning can be differentiated by performing a stool culture whereby the specific toxins in the stool can be detected if it is food poisoning and also toxin testing can be done(Riddle et al, 2016). For Clostridiumdifficile colitis, stool test for C difficile toxin would show positive results(Riddle et al, 2016). Protozoal infections such as amebic dysentery or giardiasis can show symptoms such as diarrhea and abdominal pain. Stool microscopy can be utilized in the identification of parasites such as Entamoebahistolytica or Giardia lamblia (Riddle et al, 2016). In order to confirm a gastroenteritis diagnosis, stoolmicroscopy and culture can be used as the differentiating tests (Munnink&Hoek, 2016).Assessing the Abdomen Essay
Humphries R &Linscott A. (2015).Laboratory Diagnosis of Bacterial Gastroenteritis.American Society for Microbiology. 1(1).
Munnink B &Hoek L. (2016).Viruses Causing Gastroenteritis: The Known, The New and Those Beyond. Viruses.8(2), 42.
Rached A & Haji W. (2016).Eosinophilic gastroenteritis: Approach to diagnosis and management. World J Gastrointest Pharmacol Ther. 7(4), 513–523.
Riddle M, Hebert P & Connor B. (2016). ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. TheAmerican Journal of Gastroenterology. 1(111), 602–622. Assessing the Abdomen Essay
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