Posted: February 15th, 2022
Lab Assignment: Assessing the Abdomen
A thorough examination of your patient’s belly can reveal important information regarding his internal organs. Changing the order in which these diagnostic techniques are performed may cause the regularity of bowel sounds to fluctuate, resulting in less reliable results. When it comes to abdominal pain, the history of the current illness should include information such as the onset, length, features, exacerbating, and relieving symptoms, among other things. One of the most important questions to ask before the exam begins is where it will be held (Ball,2015)—specifying which portion of the abdomen was involved in elucidating questions answered during the ROS, completely absent.
According to Ball et al. (2015), it is critical that while providing treatment to a patient with diffuse abdominal pain, the physician obtains a full subjective background of the pain to more effectively limit down probable diagnostic information. The most common complaint should be “my stomach hurts.” The HPI should include the duration and qualities of abdominal pain. More data about the patient’s condition regarding the current situation and health in general from the past is required; this could be obtained by asking more relevant questions. More examination of the patient’s diet and medical history should be conducted before diagnosing the disease.
In the scenario, more data about the patient’s current condition (HPI) and overall health from the past is required in the subjective section of the SOAP notes. This could be obtained by asking more targeted questions about the health history. More examination of the patient’s diet and medical history should be conducted before diagnosing the disease. It is also necessary to provide additional details about any abnormalities in appetite or bowel movements. Patient reports of not taking his meds would be filed under drugs the last time she took them, and each dosage reason for taking it, as well as the basis for stopping it, would be documented. It is possible that the adverse colorectal cancer finding stated was a result of a differential diagnostic consideration; hence, it must be included in the assessment section. Finally, the family background must be traceable back two generations, with two out of three generations documented. It appears that this practitioner became distracted by his ROS and either forgot to record the remainder of the PMHx or ultimately failed to complete it. Diabetes and hypertension questionnaires, which include questions about diet and activity, are good practice and essential for adequate medical documentation.
In the objective section of the SOAP note, the report still requires more details on the patient’s general look than is currently available. This comprises the rate at which the client answers questions, whether or not all questions are adequately answered, whether or not the patient’s cleanliness is good, mood, and posture. The inspection results and pounding of the abdomen were not disclosed, even though auscultation was performed, which revealed hyperactivity and discomfort in the left lower quadrant of the stomach. The physical examination has been cancelled. Components are systematically stated in a specific order to ensure that head to toe examinations are consistent (WebMD. 2017).
This section is devoid of any general assessment. For the objective area of the SOAP note, only relevant development and relevant negative discoveries are required. When using the body systems described, they must be used in a specific order. General, Neck, Chest, Abdomen, and Urogenital would be the SOAPs for the case study’s organ systems. All tissues that could be the source of abdominal pain are located in these regions. Two significant findings necessitated the use of manipulation and a stethoscope on the part of this practitioner. For palpation and capnography to be documented, the adverse effects for the rest of the assessment must be reported as well. Finally, if JR has a propensity of GI bleed, where are the CBC, face pallor, and cap refills that should have been done? If JR is a diabetic who is experiencing diarrhoea, where are his blood sugar levels and CMP readings? What is the nature of the palpation observations in the LLQ? There is a mass, or there isn’t a mass. Tenderness on the rebound? Is the sound sharp or dull when it travels? With the father’s remark not having colon cancer, the clinician might have guessed something was up. Additionally, a colorectal exam was conducted in conjunction with a prostate screening. EGD/colonoscopy is recommended, especially given his high risk of colon related cancer and history of gastrointestinal bleeding.
Does subjective and objective information support the assessment? Why or why not?
Concerning subjective and objective information, the assessment is partially supported and partially not supported. For instance, the Gastroenteritis assessment is accompanied by the patient’s primary complaint, which includes stomach problems, diarrhoea, and nausea, among other things. The symptoms of GastroenteritisGastroenteritis include stomach cramps, watery diarrhoea (often bloody), fever, nausea, aching, and headache. The personal information provided by the patient supported the gastroenteritis diagnosis; however, the objective information contained in the SOAP note was not taken into consideration in the diagnosis.
Diagnostic tests appropriate in this case.
1. Stool occult test: This test will determine whether blood is present in the stool. This is not the expected outcome. In the case of the presence of blood in the urine that cannot be seen with the naked eye, this would be a sign of a severe problem in the upper digestive system.
2. There are various blood tests available, such as a complete blood count, a basic metabolic panel, magnesium and phosphorus levels, and stool samples. Because the patient is experiencing a low-grade fever, it is critical to rule out the possibility of an infection. Because the person has symptoms of regular diarrhea, the CMP would provide information on the current health condition of the kidneys, stomach, and electrolytes.
3. Liver function test – as the name implies, liver function tests are performed in order to detect how well the liver is functioning. Suppose the liver is not performing its primary function of eliminating hazardous substances from the body. In that case, a test may be necessary to determine whether the liver has been compromised in any way. Having toxins removed from the body can result in severe abdominal discomfort, which can be felt in the lower part of the belly.
4. Ultrasound of the abdomen — This is a painless method of imaging that allows one to get an excellent image of all of the organs in the abdomen, including the kidneys, stomach, gallbladder, spleen, and pancreas, without having to go through any discomfort (Martin, L. 2016).
5. Due to the high expense of these tests and the possibility of a positive result from the tests above, an X-ray of the stomach and a CT scan of the abdomen and pelvis would be performed last.
In conclusion, I would not accept the diagnosis because of the objective evidence of pain in the left lower quadrant. The patient’s subjective data indicates that they have GastroenteritisGastroenteritis, as evidenced by a low-grade temperature, diarrhoea, nausea and vomiting, as well as stomach pain. In this patient’s case, three possible conditions could be considered a diagnostic process. These are as follows:
1. Obstruction of the intestines
This occurs when food is unable to travel through either the large or small intestines without being obstructed. An intestinal obstruction is characterized by symptoms such as abdominal aches, stomach cramps, nausea, vomiting, constipation, and dizziness.
This term refers to bulk objects that accumulate in the gallbladder, causing it to become clogged. It manifests itself in the form of nausea, diarrhea, gastritis, and stomach pain.
3. H. Pylori
This is caused by a bacterial infection of the stomach. Abdominal pain, nausea, loss of appetite, cramping, and nausea are among the symptoms of this condition.
Ball, Colledge, H., & Cafasso, J. (2015, September 13). H. pylori Infection: Causes, Symptoms, and Treatment. Retrieved from http://www.healthline.com/health/helicobacter-pylori?m=0#overview1
Martin, L. J. (2016, May 1). Gastroenteritis (Stomach ‘Flu’). Retrieved from https://www.webmd.com/digestive-disorders/gastroenteritis#1
Mayo Foundation for Medical Education and Research. (2015, December 31). Intestinal obstruction Symptoms and causes – Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/dxc-20168463
WebMD. (2017). Gallstones Picture, Types, Causes, Risks, Symptoms, Treatments. Retrieved from http://www.webmd.com/digestive-disorders/gallstones#2
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