Week 6: Assessment of the Abdomen and Gastrointestinal System Paper

Week 6: Assessment of the Abdomen and Gastrointestinal System Paper

Week 6: Assessment of the Abdomen and Gastrointestinal System Paper

The provided SOAP note demonstrates a 47-year-old Caucasian female who presented to the clinic complaining of generalized abdominal pain, nausea, and diarrhea for the past 3 days. The patient reports a history of GI bleeding, about 4 years ago, which to her knowledge was effectively resolved. She is currently on antihypertensives and diabetes medications to manage her HTN and DM respectively. The patient reports taking alcohol occasionally but denies using tobacco or any other illicit drug. Upon conducting a physical examination, it was noted that the patient’s pain originates from the left lower quadrant of her abdomen, in addition to hyperactive bowel sounds. The provided assessment results suggest that the patient is suffering from gastroenteritis. This discussion provides a comprehensive analysis of the subjective and objective portion of the provided SOAP note, in addition to the required diagnostic tests, and differential diagnosis based on the patients presenting symptoms and physical examination results.

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Analysis of Additional Subjective Information Top of Form

From the provided subjective data, the patient has mentioned that she has abdominal pain but does not point out where it’s exactly located. She also fails to give characteristics of the pain, whether dull or throbbing. The timing, frequency, and alleviating and aggravating factors are also missing. Given that the patient also reported diarrhea, it was necessary to provide more information regarding the characteristic of the stool, and characteristics of her bowel movement to help with the differential diagnosis (Mrouf et al., 2017). For the patient current medication, it was necessary to provide more details regarding the dosage, frequency, and period of use. This information helps in formulating the care plan to avoid a drug-drug reaction and adverse effects. Abdominal pain may also be associated with other lifestyle factors. As such, the patient needs to provide more information regarding her diet and exercise. Such details will help suggest the most possible diagnosis.

Analysis of Additional Objective information

The objective portion of the patient history is supposed to build on the chief complaint among other details provided in the subjective data. However, it is crucial to conduct a head-to-toe physical assessment for the patient given her age and comorbidities, just to make sure that she is in good health. The collected objective data report pain in the left lower quadrant of the patient’s abdomen and hyperactive bowel sound. This information is quite limited to confirming the primary diagnosis. As a result, it was necessary to provide findings of abdominal inspection for hernias, bulges, masses, enlarged veins, and inability to lie flat (Ball et al., 2019). Considering that the patient has a history of GI bleeding, it is necessary to consider visual examination of the entire abdomen to confirm whether the problem was resolved completely, or is associated with the current condition. Nutritional assessment of the patient is also necessary to determine whether the patient’s symptoms are associated with food poisoning or other dietary factors.

Is this Assessment Supported by the Subjective and Objective Assessment?

The patient assessment suggests gastroenteritis which is not fully supported by both the subjective and objective data. From the patient history of presenting illness, the main symptoms presented by the patient include abdominal pain, nausea, and diarrhea. With the numerous related abdominal conditions, these symptoms alone are quite limited to suggest the diagnosis. The history of GI bleeding, however, helps to narrow down to a few options. Consequently, the objective data further limits the location of the pain to the left lower quadrant which suggests gastroenteritis (Mrouf et al., 2017). However, this information is still quite limited to support a primary diagnosis of gastroenteritis. Additional tests must be ordered to confirm this diagnosis.

Appropriate Diagnostic Tests

Patients with gastrointestinal complications normally display similar symptoms such as pain, diarrhea, and nausea just like the patient in the provided case study. Differentiatingthese conditions, and avoiding instances of misdiagnosis thus depends on diagnostic tests such as complete blood count to rule out infections (Mrouf et al., 2017). For the patient in the provided case study, it is necessary to order a rapid stool test to find out whether there is the presence of rotavirus or norovirus, which are the most common causes of gastroenteritis as per the assessment. Additionally, it is necessary to order basic metabolic panel tests to determine whether the patient’s preexisting conditions such as diabetes are well managed, given that the patient is also overweight. Lastly, imaging studies such as x-Ray and CT scan of the entire abdomen is necessary to assess for visual abnormalities which might be causing the patient’s symptoms. A primary diagnosis will only be made based on the results of the ordered diagnostic tests.

Current Diagnosis

The current diagnosis suggests gastroenteritis, which has not been supported by lab evidence confirming the presence of the causative microorganisms. As such, I will not accept this diagnosis but still, it can be a possible reason behind the patient’s symptoms. Most of the time, gastroenteritis is diagnosed based on a complete history of the patient’s symptoms in addition to finding from the physical examination. However, it is suggested that patients with blood in stool or fever undergo stool study tests (Sunkara et al., 2019). This was not done for the above patient despite reporting a history of GI bleeding four years ago. It is also necessary to rule out other conditions which cause similar symptoms such as inflammatory bowel disease, irritable bowel syndrome (IBS), and intestinal obstruction among others.

Differential Diagnosis

1. Inflammatory bowel disease (IBD): This condition normally results from chronic inflammation of the GI tract leading to ulcerative colitis and Crohn’s disease (Seyedian et al., 2019). Some of the common symptoms of IBD include persistent diarrhea, abdominal pain, and blood in stool or GI bleeding, just as displayed by the patient in the provided case study. However, to confirm IBD diagnosis, a combination of colonoscopy or endoscopy and imaging studies of the abdomen is required.
2. Irritable bowel syndrome (IBS): This is one of the most common complications of the GI tract leading to bloating, abdominal pain, and diarrhea or constipation (Lacy, & Patel, 2017). The patient in the provided case study reported most of these symptoms making IBS a possible diagnosis. However, IBS diagnostic criteria depend on the frequency of the pain and associated abdominal discomfort, in addition to lab tests such as stool tests to examine for parasites or bacteria.
3. Intestinal Obstruction: This condition normally occurs when there is partial or complete GI blockage because ofinflammation, hernia, or adhesion (Jackson, & Cruz, 2018). The patient will present with abdominal pain, and nausea, as displayed by the patient, in addition to other symptoms such as malaise, bloating dehydration, and constipation. The patient in the provided case study however reported diarrhea which rules out this diagnosis.

Conclusion

The provided case study demonstrates a patient with GI symptoms such as abdominal pain, nausea, and diarrhea. The subjective and objective portion of the patient information suggests a diagnosis of gastroenteritis, with IBD, IBS, and intestinal obstruction being possible diagnoses. However, the information is quite limited to narrow down to a definitive diagnosis. As such, it is essential for additional diagnostic tests, such as rapid stool tests to be ordered, to confirm the primary diagnosis and rule out the differentials.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.ISBN: 9780323545389

Jackson, P., & Cruz, M. V. (2018). Intestinal obstruction: evaluation and management. American family physician, 98(6), 362-367.PMID: 30215917.

Lacy, B. E., & Patel, N. K. (2017). Rome criteria and a diagnostic approach to irritable bowel syndrome. Journal of clinical medicine, 6(11), 99. https://doi.org/10.3390/jcm6110099

Mrouf, A., Albatish, I., Mosa, M. J., & Abu-Naser, S. S. (2017). Knowledge-Based System for Long-term Abdominal Pain (Stomach Pain) Diagnosis and Treatment. http://dstore.alazhar.edu.ps/xmlui/handle/123456789/367

Seyedian, S. S., Nokhostin, F., & Malamir, M. D. (2019). A review of the diagnosis, prevention, and treatment methods of inflammatory bowel disease. Journal of medicine and life, 12(2), 113.DOI: 10.25122/jml-2018-0075

Sunkara, T., Rawla, P., Yarlagadda, K. S., & Gaduputi, V. (2019). Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clinical and experimental gastroenterology, 12, 239.DOI: 10.2147/CEG.S173130.

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Week 6: Assessment of the Abdomen and Gastrointestinal System
On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?
Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.
This week, you will explore how to assess the abdomen and gastrointestinal system.
Learning Objectives
Evaluate abnormal abdomen and gastrointestinal findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
Analyze chest X-Ray and abdominal X-Ray imaging
Identify concepts, theories, and principles related to advanced health assessment
This week, you will complete the analysis of the SOAP note provided.
J.R, 47 y.o Female here for complains of having generalized abdominal pain that started 3 days ago.
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.
Please analyze your SOAP more as a narrative so that you are able to correctly explain your analysis of findings. Please include Presentation page and References on the bottom of your assignment as usual.

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RUBRIC
With regard to the SOAP note case study provided, address the following:
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the subjective portion of the SOAP note and lists detailed additional information to be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
10 (10%) – 12 (12%)
The response clearly, accurately, and thoroughly analyzes the objective portion of the SOAP note and lists detailed additional information to be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
14 (14%) – 16 (16%)
The response clearly and accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a thorough and detailed explanation.
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
18 (18%) – 20 (20%)
The response thoroughly and accurately describes appropriate diagnostic tests for the case and explains clearly, thoroughly, and accurately how the test results would be used to make a diagnosis.
· Would you reject or accept the current diagnosis? Why or why not?
· Identify three possible conditions that may be considered as a differenial diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
23 (23%) – 25 (25%)
The response states clearly whether to accept or reject the current diagnosis, with a thorough, accurate, and detailed explanation of sound reasoning. The response clearly, thoroughly, and accurately identifies three conditions as a differential diagnosis, with reasoning that is explained clearly, accurately, and thoroughly using at least three different references from current evidence-based literature.
20 (20%) – 22 (22%)
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 (5%) – 5 (5%)
Uses correct APA format with no errors.