wk 6 The Episodic Note Case Study: Abdominal Assessment

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Case Study Analysis Assessment of the Abdomen and Gastrointestinal System

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Case Study Analysis Assessment of the Abdomen and Gastrointestinal System

Additional information that should be included in the documentation of subjective data

When a healthcare professional receives subjective data, the patient's perspective is considered. This way encompasses all the worries, sentiments, and impressions that are gleaned during interviews. Abdominal discomfort was the patient's primary complaint in the scenario, making it crucial to have information regarding the quality and location of the pain, whether it is migratory, localized, increases or decreases in severity, or where it comes from and radiates outward. In addition, it is essential to note if the discomfort started suddenly or gradually. The patient should be questioned about what he was doing at the time when the discomfort began. It is impossible to overstate the significance of figuring out what is causing the pain and what is helping to relieve it. Several possible diagnoses may be narrowed down using this information (Ball, Dains, Flynn, Solomon, & Stewart, 2019). 

It's essential to have a complete picture of the patient's bowel and urine routines, even if they only mentioned diarrhea. Included in this information are the frequency and length of episodes, the elements that alleviate or exacerbate the condition, and any other symptoms that may accompany diarrhea. Additional information on urinary behaviors such as incontinence, hesitation, dysuria, or urgency should also be provided. It is essential to detail the odor, color, and pain after or during the bowel movement. Poop lightening and urine darkening are common symptoms that can bring light to differential diagnoses like hepatitis. (Ball, Dains, Flynn, Solomon, & Stewart, 2019). In order to rule out other possible symptoms, such as nausea and vomiting, it is essential to look into the possible causes of stomach discomfort.

The patient had a history of gastrointestinal bleeding four years earlier. There should be information on whether vomitus or stool has blood in it and its color and smell. There should be some information on his medication compliance as he takes medicine for hypertension and diabetes. In order to assess the likelihood of abdominal damage, it is necessary to incorporate information about the patient's profession.

Additional information that should be included in the documentation of objective data

Different systems must be examined to get a comprehensive and thorough evaluation of a complaint of abdominal discomfort. Following a complete visual assessment, the examiner will do an abdominal exam that includes auscultation, percussion, and palpation while keeping a close eye on the patient for any signs of resistance, grimacing, or recoiling. To rule out other urgent diagnoses like testicular torsion or an incarcerated hernia which can be discarded by doing a deeper examination of the groin and the genital region (Ball, Dains, Flynn, Solomon, & Stewart, 2019). A percussive examination of the flank may rule out renal calculi, and additionally search for frank urinary bleeding can bring a hint. The lungs, heart, head, neck, and musculoskeletal system may also be examined since stomach discomfort might be referred from other locations (Dains, Linda, Baumann, & Scheibel, 2019). 

Whether the assessment is supported by the subjective and objective information

According to the evaluation, the diagnosis in this patient is left lower quadrant discomfort and gastroenteritis. Both the subjective and objective evidence strongly supports this conclusion. The client presented complaints of pain in the left lower quadrant, which is somewhat corroborated by a symptom of widespread abdominal discomfort and diarrhea but not vomiting. The rating of pain level is missing from the patient history, but the vital signs are slightly elevated, which means the level of pain is moderate because the heartbeat is higher in severe pain.

Another meaningful sign is the abdomen which, even with pain, is soft, meaning that no acute severe pathology like appendicitis is established (Vaghela & Shah, 2017). The ileum, rectum, left ureter, and certain colon sections are in the left iliac fossa. Gastroenteritis was likely to blame for the patient's left lower quadrant discomfort and principal diagnosis because it is one of the most frequent abdominal pathologies (Stuempfig & Seroy, 2022).

Most appropriate diagnostic tests for this case and how results would be used in making a diagnosis

A complete blood count (CBC) with differential to evaluate the possibility of sepsis as a cause, a complete metabolic profile including liver and kidney functions tests, urinalysis, and coagulation panel are some laboratory tests that can be used in the diagnosis of acute abdominal pain. An abdominal CT scan can be beneficial to discard other acute pathologies or neoplastic problems, pelvic ultrasound, or radiographic investigations that can show the colon's inflammation evidenced by gases level. These tests are imperative to identify the appropriate diagnosis (Vaghela & Shah, 2017).

Whether I would accept/reject the current diagnosis

This case study's results include discomfort and gastroenteritis in the left bottom quadrant. The assessment is based on the physical examination results and the diagnosis of gastroenteritis as a possible cause of lower quadrant discomfort. Gastroenteritis symptoms, such as diverticulitis and colitis, are common. As a result, there is no evidence to support the conclusions drawn from this assessment as part of an evaluation segment inside a soap note. Lab findings, diagnoses, differential diagnoses, existing co-morbidities, and a plan to touch base on a precise diagnosis or analysis should have been mentioned in this section (Stuempfig & Seroy, 2022). A few differentiating analyses would be essential from the most implausible to the least improbable. If the assessment information is unclear, it is required to integrate these methods since this section is where the subjective evidence combines with the objective evidence to come up with a solid result.

Possible differential diagnoses

The most common diagnosis, gastroenteritis, may have been diagnosed if the SOAP data is correct. Stomach discomfort, diarrhea, and nausea may also be linked to a range of diseases, including gastroenteritis, diverticulitis, colitis, and appendicitis (Ball et al., 2019). We suspected diverticulitis or unusual appendicitis when the patient had left lower quadrant pain. It can be later confirmed upon examination with laboratory and imaging results. Diverticulitis is very rare in persons under the age of 40 years old (Stuempfig & Seroy, 2022). Atypical left appendicitis (LSAA) affects males 1.5 times more often than women, and it typically strikes between the ages of 8 and 64 (Dains et al., 2019). Celiac disease, Crohn's disease, H-Pylori, and ulcerative colitis are all examples of upper abdominal conditions that might indicate colitis (Vaghela, & Shah, 2017).

References

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

Dains, J. E., Linda Ciofu Baumann, & Scheibel, P. (2019).  Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Stuempfig ND & Seroy J.(2022). Viral Gastroenteritis. In: StatPearls. Treasure Island (FL). Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK518995/

Vaghela, K., & Shah, B. (2017). Diagnosis of Acute Appendicitis Using Clinical Alvarado Scoring System and Computed Tomography (CT) Criteria in Patients Attending Gujarat Adani Institute of Medical Science - A Retrospective Study.  Polish journal of radiology, 82, 726–730. https://doi.org/10.12659/PJR.902246