Assignment; Lab Assignment: Assessing the Abdomen Essay

Assignment; Lab Assignment: Assessing the Abdomen Essay

Assignment; Lab Assignment: Assessing the Abdomen Essay

Assignment; Lab Assignment: Assessing the Abdomen Sample Essay

The SOAP note details the history and examination of JR a 47-year-old white male with complains of persistent abdominal pain and diarrhea. Physical examination reveals left lower quadrant and hyperactive bowel movements indicative of a possible gastroenteritis diagnosis. This paper will analyze the subjective and objective details of the SOAP note.

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Subjective Portion

JR had two major complains but only one of them (abdominal pain) was discussed in details. The patient was to be probed on the frequency of the diarrhea, the volume and consistency, the color, presence of blood stains and any accompanying symptoms such as thirst, dry mucous membranes and decreased urine output which could be indicative of dehydration(Meisenheimer et al., 2022).Other additional symptoms such as fever, vomiting or nausea should be ruled out. In the past medical history, the year of onset of the chronic illnesses should be included. The social history should quantify the social drinking and the type of alcohol taken. Review of systems could also be essential in ruling out other diseases.

Objective Portion

The objective data given does not reveal the general JR. It should include the patients’ general appearance, if he is in distress, obvious pain, appears dehydrated, pale, cyanosed, jaundiced or edematous. Physical examination of the affected system should have been thorough where examination details on inspection could have included the symmetry, scars, distention or any visible vessels. On palpation masses, organomegally, guarding and tenderness should be ruled out. The percussion should also be noted. It is important to note the rate of bowel sounds (DiLeo Thomas & Henn, 2021).

Assessment Portion

The assessment findings are supported by both objective and subjective data apart from the fact that the abdominal pain was generalized and not specific as opposed to the physical findings.

Diagnostic Test

The patient could have benefited from laboratory tests such stool for ova and cyst, stool for microscopy, culture and sensitivity and a complete blood count. An abdominal ultrasound could have been vital in probing the cause of the abdominal pain and the left lower quadrant pain.

Differential Diagnosis

Pain is not a differential diagnosis but rather a symptom thus the differential diagnosis of left lower quadrant pain does not hold water. It should rather explore some of the conditions that can cause  lower quadrant pain such as diverticulitis(Galgano et al., 2019). Others include inflammatory bowel disease and irritable bowel syndrome. Gastroenteritisis supported by the data provided.

Conclusion

The subjective and objective data provided in the case of JR was not as detailed as it is recommended. The patient could have greatly benefited from several laboratory investigations such as stool analysis, complete blood count and even an abdominal ultrasound. From the history the patient is likely to be suffering from acute gastroenteritis which is mostly infective like bacterial, viral, diverticulitis or inflammatory bowel disease.

References.

DiLeo Thomas, L., & Henn, M. C. (2021). Perfecting the Gastrointestinal Physical Exam. Emergency Medicine Clinics of North America, 39(4), 689–702. https://doi.org/10.1016/j.emc.2021.07.004

Galgano, S. J., McNamara, M. M., Peterson, C. M., Kim, D. H., Fowler, K. J., Camacho, M. A., Cash, B. D., Chang, K. J., Feig, B. W., Gage, K. L., Garcia, E. M., Kambadakone, A. R., Levy, A. D., Liu, P. S., Marin, D., Moreno, C., Pietryga, J. A., Smith, M. P., Weinstein, S., & Carucci, L. R. (2019). ACR Appropriateness Criteria® Left Lower Quadrant Pain-Suspected Diverticulitis. Journal of the American College of Radiology, 16(5), S141–S149. https://doi.org/10.1016/j.jacr.2019.02.015

Meisenheimer, E. S., Epstein, C., & Thiel, D. (2022). Acute Diarrhea in Adults. American Family Physician, 106(1), 72–80.

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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:
  • 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. 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.
  • 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 three different references from current evidence-based literature.
  • 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.