Assessing the Abdomen Assignment Paper

Assessing the Abdomen Assignment Paper

Assessing the Abdomen Assignment Paper

The SOAP note concerns a 47-year-old female patient with diarrhea and generalized abdominal pain whose onset was three days ago. The abdominal exam includes a soft abdomen, hyperactive bowel sounds, and LLQ pain. The assessment findings include LLQ pain and gastroenteritis (GE). The purpose of this paper is to analyze the SOAP note, identify appropriate diagnostic tests, and discuss possible conditions.

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Subjective Portion

The HPI in the subjective portion should have provided additional information on the abdominal pain and diarrhea characteristics. For example, if it is sharp, dull, colicky, or crampy, and if it is constant or radiating. Diarrhea should be described whether it is watery, bloody, or malodorous, and the color of the stool should be included. In addition, it should include the duration of the pain and timing, like if it occurs before or after meals (Mealie & Manthey, 2019). Besides, the aggravating and alleviating factors and associated symptoms should be provided. The subjective portion should also include the patient’s immunization and surgical history. Furthermore, a review of systems (ROS) should be included indicating the positive and negative symptoms in each body system. 

Objective Portion

The objective portion should include the patient’s general assessment findings. This includes appearance, hygiene, mannerism, facial expressions, speech, orientation, and attitude towards the clinician. The abdominal exam findings should also be comprehensive since this is a focused abdominal assessment. It should include comprehensive findings from the abdominal inspection, auscultation, percussion, and palpation. Inspection findings include the abdomen’s symmetry, contour, respiratory movements, pigmentation, and scars. Auscultation should also have included the presence of vascular sounds and friction rubs (Mealie & Manthey, 2019). Findings from percussion and palpation of the liver, spleen, stomach, and kidney should also be included.

Assessment

Subjective and objective findings support the assessment findings of GE and LLQ pain. GE is supported by findings of diarrhea, generalized abdominal pain, mild fever (99.8), and hyperactive bowel sounds. In addition, LLQ pain is supported by pertinent findings of abdominal pain in the left lower quadrant.

Diagnostic Tests

Diagnostic tests appropriate for this case include complete blood count (CBC), stool culture for ova and cyst, and abdominal ultrasonography. A CBC will help identify signs of infection based on the white blood cell (WBC) count. A routine stool culture identifies three primary bacteria Campylobacter, Salmonella, and Shigella. The stool culture for ova and cyst will help determine the cause of diarrhea and identify the specific pathogen, guiding the treatment interventions (Hiner & Walters, 2021). Furthermore, abdominal ultrasonography is essential in helping to identify if the patient has an inflammation of the abdominal organs, which often causes abdominal pain, nausea, and diarrhea.

Differential Diagnosis

The diagnosis of LLQ pain would be rejected because it is an objective finding rather than a medical diagnosis. The finding should be used to identify the possible condition associated with LLQ pain. However, the GE diagnosis would be accepted because it is supported by pertinent positive signs and symptoms of abdominal pain, LLQ tenderness, diarrhea, mild fever, and hyperactive bowel sounds (Orenstein, 2020). The possible conditions are:

Acute Gastroenteritis

GE is characterized by inflammation of the stomach and intestinal tract’s mucosal membrane resulting in an increased frequency of watery stools and vomiting. Patients with acute GE pass loose stools at least three times a day. They also report nausea, increased body temperature, and generalized abdominal pain. Physical findings in GE include elevated body temperature, hyperactive bowel sounds, and abdominal tenderness (Orenstein, 2020). Acute GE is a differential diagnosis based on the patient’s positive findings of diarrhea, abdom9nal pain, low-grade fever, abdominal tenderness, and hyperactive bowel sounds.

Ulcerative Colitis

Ulcerative Colitis (UC) is characterized by an extensive inflammation of the rectum and rectosigmoid colon. It presents with episodic remissions and exacerbations attributed to factors like intestinal infections. Patients with moderate UC present with more than four stools/day, with or without blood. In addition, they have intermittent nausea and mild abdominal pain (Porter et al., 2020). In severe UC, the intestinal lining often bleeds, resulting in small erosions and ulcers. UC is a possible diagnosis based on the patient’s findings of nausea, generalized abdominal pain, diarrhea, and mild fever. In addition, the patient’s history of GI bleed makes UC a likely diagnosis.

Diverticulitis

Diverticulitis presents with inflammation of one or more diverticula, which develop at points of weakness in the intestinal wall. Clinical manifestations of diverticulitis include nausea, tachycardia, low-grade fever, abdominal pain localized to LLQ, and constipation (Strate & Morris, 2019). Diverticulitis is a differential diagnosis based on the patient’s clinical manifestations of LLQ pain, nausea, and mild fever. However, it is an unlikely primary diagnosis since the patient has no constipation.

Conclusion

The objective portion should have included the characteristics of the patient’s abdominal pain and diarrhea and exacerbating and relieving factors. It should also include the surgical and immunization history and ROS. The objective part should have detailed abdominal and general exam findings. Possible conditions include Acute GE, Ulcerative colitis, and diverticulitis.

References

Hiner, G. E., & Walters, J. R. (2021). A practical approach to the patient with chronic diarrhea. Clinical medicine (London, England), 21(2), 124–126. https://doi.org/10.7861/clinmed.2021-0028

Mealie, C. A., & Manthey, D. E. (2019). Abdominal exam. In StatPearls [Internet]. StatPearls Publishing.

Porter, R. J., Kalla, R., & Ho, G. T. (2020). Ulcerative colitis: Recent advances in the understanding of disease pathogenesis. F1000Research, 9, F1000 Faculty Rev-294. https://doi.org/10.12688/f1000research.20805.1

Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1

Strate, L. L., & Morris, A. M. (2019). Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology, 156(5), 1282–1298.e1. https://doi.org/10.1053/j.gastro.2018.12.033

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Assignment 1: Lab Assignment: Assessing the Abdomen
To Prepare
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:
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.
The Assignment
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
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.
1. In this Assessment 1 Assignment, you will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. This is in a scholarly paper format and not SOAP format this week. 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. Follow the rubric…..Be sure to use APA format…..and upload by Day 7.

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

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.
7 (7%) – 9 (9%)
The response accurately analyzes the subjective portion of the SOAP note and lists additional information to be included in the documentation.
4 (4%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the subjective portion of the SOAP note and vaguely and/or with some inaccuracy lists additional information to be included in the documentation.
0 (0%) – 3 (3%)
The response inaccurately analyzes or is missing analysis of the subjective portion of the SOAP note, with inaccurate and/or missing additional information 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.
7 (7%) – 9 (9%)
The response accurately analyzes the objective portion of the SOAP note and lists additional information to be included in the documentation.
4 (4%) – 6 (6%)
The response vaguely and/or with some inaccuracy analyzes the objective portion of the SOAP note and vaguely and/or inaccurately lists additional information to be included in the documentation.
0 (0%) – 3 (3%)
The response inaccurately analyzes or is missing analysis of the objective portion of the SOAP note, with inaccurate and/or missing additional information 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.
11 (11%) – 13 (13%)
The response accurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an explanation.
8 (8%) – 10 (10%)
The response vaguely and/or inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with a vague explanation.
0 (0%) – 7 (7%)
The response inaccurately identifies whether or not the assessment is supported by the subjective and/or objective information, with an inaccurate or missing 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.
15 (15%) – 17 (17%)
The response accurately describes appropriate diagnostic tests for the case and explains clearly and accurately how the test results would be used to make a diagnosis.
12 (12%) – 14 (14%)
The response vaguely and/or with some inaccuracy describes appropriate diagnostic tests for the case and vaguely and/or with some inaccuracy explains how the test results would be used to make a diagnosis.
0 (0%) – 11 (11%)
The response inaccurately describes appropriate diagnostic tests for the case, with an inaccurate or missing explanation of 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.