The Assignment
- 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? Provide reference for using the diagnostic test
- 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.
You have an assignment which is to analyze the SOAP note given to you. Submit your assignment in a Word document. This should be written in a narrative format and not a SOAP note.
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. 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, 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.
Abdominal Assessment
Student’s Name
Institutional Affiliations
Abdominal Assessment
Subjective Section
The information provided in this section is not adequate to warrant a diagnosis. Therefore, information is required to increase the chances of a more accurate diagnosis. Missing information includes the assessment of HEENT, Respiratory, gastrointestinal, genitourinary, cardiovascular, musculoskeletal, lymphatic, neurological, psychiatric, hematologic, endocrine, and functional status systems should be added (Hall, 2020). Additional information should include any past abdominal treatment such as ulcers and others. The patient just stated that his stomach hurts. He should be allowed to describe the nature of the pain to help inaccurate diagnosis. For example, pain can be dull or sharp, also, it might be associated with a position, eating, or any other activity (Penner et al., 2020). The care provider should ask the patient whether he has had blood in stool, nausea/vomit, or intolerance to particular foods.
Objective Section
Similarly, the information provided under the subjective section is not sufficient to arrive at a diagnosis, therefore, additional information is need. It should include physical examination in all areas to rule out most illnesses (Hall, 2020). Using a stethoscope, the care provider may perform auscultation to listen to the bowel sounds. Hyperactive bowel sounds are normally present if the patient has diarrhea. Patients may be palpated to detect any rigidity, tenderness, masses, or any other risk. Percussion is a type of physical examination that may also be applied to detect tenderness (Hall, 2020). Rectal examination is also important to note the presence of the rectal vault. Colonoscopy may be recommended to detect changes or abnormalities in the large intestine and colon.
Assessment
The assessment indicates that the patient has Gastroenteritis, however, this assessment is not supported sufficiently by subjective and objective data. The subjective data relevant to the illness include fever and abdominal cramps. The objective data may include watery or bloody diarrhea and vomit (Penner et al., 2020). The assessment indicates left lower quadrant pain, which is shown in the subjective data. However, the objective data does not support the assessment at all. The patient needs adequate diagnostic tests to support and show accurately that he is suffering from Gastroenteritis. Tests would also separate whether he has viral or bacterial Gastroenteritis.
Diagnostic Tests
A stool culture may be orders to detect any viral or bacterial infection that could be causing the illness. Additionally, a complete blood count is recommended to evaluate white blood cells, red blood cells, platelets, hemoglobin, and hematocrit (Penner et al., 2020). The complete blood count can evaluate the overall health and detect a variety of diseases and conditions, such as infections, anemia, and leukemia. An elevated white blood cell count would confirm an underlying infection. A creatinine test may also be conducted to evaluate kidney function. An increased level of creatinine may be a sign of poor kidney function (Penner et al., 2020). A colonoscopy may be ordered to examine problems in the colon if any. These diagnostic tests are likely to result in a more accurate diagnosis.
Differential Diagnoses
The current diagnosis is Gastroenteritis. However, I would reject the current diagnosis because the objective and subjective information are not sufficient to arrive at a diagnosis. The accuracy of the diagnosis is not certain, further tests and physical examination are needed to be sure of the patient’s illness. Below are some possible differential diagnoses for this patient.
Ulcerative Colitis
It is an inflammatory bowel disease that leads to inflammation and ulcers in the digestive tract, specifically, colon and rectum. Symptoms include diarrhea, abdominal pain, fatigue, fever, and urgency to defecate (Gajendran et al., 2019). Sometimes blood in the stool may be detected.
Food Poisoning
Food poisoning results from eating contaminated, toxic, or spoilt food. Symptoms include diarrhea, abdominal pain, and nausea, and vomiting. The symptoms often begin suddenly a few hours after eating contaminated food (Kumar et al., 2020). Food poisoning is a differential diagnosis for this patient because his symptoms are almost similar.
Diverticulosis
Symptoms include abdominal pain on the left side, diarrhea, fever, bloody stool, nausea and vomiting, and constipation. It entails small, bulging pouches that can form in the lining of the digestive system (Rangan & Lamont, 2020). The patient experienced at least two symptoms of this illness, therefore, it is a differential diagnosis.
References
Gajendran, M., Loganathan, P., Jimenez, G., Catinella, A. P., Ng, N., Umapathy, C., … & Hashash, J. G. (2019). A comprehensive review and update on ulcerative colitis. Disease-a-month, 65(12), 100851. https://doi.org/10.1016/j.disamonth.2019.02.004
Hall, B. H. (2020). Evaluation and management of chronic pain for primary care: A pocket guide for the primary care provider. Cham: Springer.
Kumar, A. (2020). Food Poisoning: causes, precautions, diagnosis and treatment: A brief review. World Journal of Biology and Biotechnology, 5(1), 33-36. https://www.researchgate.net/publication/348557320_Food_Poisoning_causes_precautions_diagnosis_and_treatment_A_brief_review
Penner, R., Fishman, M. B., & Majumdar, S. (2020). Evaluation of the adult with abdominal pain. UpToDate, Waltham, MA. Accessed, 6. https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain
Rangan, V., & Lamont, J. T. (2020). Small bowel diverticulosis: pathogenesis, clinical management, and new concepts. Current Gastroenterology Reports, 22(1), 1-7. https://doi.org/10.1007/s11894-019-0741-2