Posted: November 6th, 2022
Patient Assessment: Gastrointestinal System.
Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.
• With regard to the Episodic note case study provided: Patient Assessment: Gastrointestinal System.
o Review this week’s Learning Resources, and consider the insights they provide about the case study.
o Consider what history would be necessary to collect from the patient in the case study.
o Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
o Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation. Patient Assessment: Gastrointestinal System.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. 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. Patient Assessment: 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. Patient Assessment: Gastrointestinal System.
• 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
• Left lower quadrant pain
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.Consider including a subject heading reflective of this content.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.Consider including a subject heading reflective of this content. Patient Assessment: Gastrointestinal System.
3. Is the assessment supported by the subjective and objective information? Why or why not? Consider including a subject heading reflective of this content.
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? Consider including a subject heading addressing this content. Patient Assessment: Gastrointestinal System.
SOAP Note Assessment of Patient JR: 47 Years Old, Caucasian, With Diarrhea and Left Lower Quadrant Abdominal Pain
An analysis of the subjective portion of patient JR’s SOAP note reveals that some additional information needed to be added. To be specific, in the history of presenting illness or HPI the nature of the symptoms is usually described using the acronym LOCATES. In the SOAP note, some of this has been done. However, what is missing are the associated factors to the abdominal pain. These would be the aggravating factors or the alleviating factors to the left lower quadrant (LLQ) abdominal pain. Also missing is information on the character of the pain. This should have described whether the pain is sharp or dull, for instance. Lastly on the HPI, the timing of the pain is not given. It is therefore difficult to establish from the SOAP note whether the pain is continuous or comes at particular times. The subjective assessment is also missing information on the immunization history of the patient. Furthermore, there is no review of systems. This should include all systems and start with the general outlook or constitutional picture. It should then review the head, eyes, ears, nose, and throat (HEENT). After the head then should follow the othet body systems such as respiratory, cardiovascular, integumentary, and so on. Patient Assessment: Gastrointestinal System.
In the analysis of the objective portion of the SOAP note, it is obvious that the patient’s body mass index or BMI has not been calculated, even though his weight and height are presented. Other missing details are on the diagnostic tests. It is improbable that a patient who presents with abdominal pain and diarrhea is treated without even a single laboratory test being done. Patient Assessment: Gastrointestinal System.
The assessment is indeed supported by subjective and objective information in the SOAP note. In gastroenteritis, the most common and predominant symptoms are usually abdominal cramps, diarrhea, nausea, and a low grade fever (Hammer & McPhee, 2018; Huether & McCance, 2017). The patient reports in the subjective portion that he has “pain” in the abdomen. It is possible that what he has are abdominal cramps. He also reports having diarrhea. In the objective portion, the patient is found to have a low grade fever which is at 99.8°F. All this goes to support the assessment of a diagnosis of gastroenteritis or GE (Fletcher, 2018). Patient Assessment: Gastrointestinal System.
Diagnostic Tests and How to Arrive at the Diagnosis
The most likely diagnostic tests that could have been done on patient J.R. include:
Taking a stool sample for microscopy would enable the identification of the microbes responsible for the gastroenteritis infection. This woild have confirmed the diagnosis beyond any reasonable doubt. Furthermore, it would have enabled the performance of culture and sensitivity tests to determine the best antibiotics to use. Endoscopy which involves visualisation of the gut through an inserted tube with a camera would have helped in ruling out other inflammatory conditions like ulcerative colitis. An abdominal ultrasound on its part would have also played a big part in ruling out the presence of kidney stones and hernia which are possible differential diagnoses (Fletcher, 2018). Lastly, a full blood count is a standard and should be done, especially because the patient has a low grade fever. It would reveal any leucocytosis ondicating infection and point towards the gastroenteritis. Other abnormalities in the blood would also be made apparent like thrombocytopenia or anemia. Patient Assessment: Gastrointestinal System.
To Reject the Current Diagnosis or Not
I would not reject the current diagnosis but accept it based only on the clinical picture (history and physical examination). The clinical picture from the subjective and objective parts of the SOAP note indeed have supported in part the current diagnosis of GE. However, the fact that no diagnostic tests were done must be taken into consideration. If these were done as explained above, the picture that would have emerged may have been different as to rule out GE and confirm another different diagnosis. As such, four very possible differential diagnoses ate likely for this patient. These are: Patient Assessment: Gastrointestinal System.
The reasoning behind this is that both ulcerative colitis and Crohn’s disease are inflammatory bowel diseases that also present with abdominal pain and diarrhea (MFMER, 2019). Irritable bowel syndrome and kidney stones also are known to present with symptoms that include abdominal pain, diarrhea, nausea, and vomiting (MFMER, 2018). Any of these conditions could potentially be responsible for patient J.R.’s symptoms as illustrated in the subjective assessment and confirmed with the objective physical examination. Patient Assessment: Gastrointestinal System.
The SOAP note for 47 year-old patient J.R. was short and not comprehensive enough. It is clear that some important details were omitted. These omitted details could have been instrumental in arriving at the diagnosis or confirming the provisional diagnosis of gastroenteritis. On the same vein, diagnostic tests done are mot shown anywhere. These are crucial in any gastrointestinal illness as many co ditioms could mimic what the clinician thinks is the diagnosis as per the history and physical examination. Patient Assessment: Gastrointestinal System.
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