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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
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)
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
Left lower quadrant pain
PLAN: This section is not required for the assignments in this course (NURS 6512)
With regard to the Episodic note case study provided:
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. Remember to use support literature with your explanations, APA writing.
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.
Note: must use at least 5 Reference in APA format
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Additional Subjective Data
Health history is crucial for obtaining the necessary clinical data from a patient. The information guides collaborative and individualized care for better outcomes (Asif et al., 2017). Additional information is necessary in the case study to guide the diagnosis towards comprehensive care. It is best to understand the nature of the abdominal pain- crampy, dull, intermittent, and whether there is a relief after going to the toilet. More information includes; associated symptoms, radiations, or exacerbating factors. It is also necessary to enquire about early satiety as a significant contribution to making a diagnosis, immunization history, sleep, exercise, diet, exercise, and any psychological problems in the patient’s life.
Additional Objective Data
Objective data are the observable and measurable aspects of a patient. The SOAP is lacking the physical presentation of the patient. It is an important component of a patients care plan (Podder & Ghassemzadeh, 2020). It would help determine the severity of the illness, social status, and the patient’s values for personalized care. A HEENT evaluation is also missing in the soap note. It is useful in obtaining more information about the patient to identify or rule out any underlying issues (Asif et al., 2017). It would also help understand any side effects or adverse reactions to the medications. Most importantly, a genitourinary system examination would be an appropriate approach for the patient because of its relationship with abdominal pain. A costovertebral angle tenderness assessment would help provide more information about any relationships to the patient's chief complaints.
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An argument for the Assessment
The purpose of assessment is to synthesize information from subjective and objective data for a diagnosis. However, there is a discrepancy between the patient's report about the nature of the pain and the physical findings. The patient reports generalized abdominal pain while the abdominal exam reveals a left-lower quadrant pain. Diagnostic tests would help in making a credible diagnosis for the patient.
A stool analysis is an appropriate test for the patient. It would help determine the presence of bacteria invasion, ova, or parasites in the intestines. Test results can help confirm conditions like inflammatory bowel disease, entamoeba histolytica, and giardiasis (Kasirga, 2019). An abdominal Ct-scan is also crucial for this patient. It helps in observing signs of inflammation, injury, infection, and existing liver, kidney, intestines, pancreas, and adrenal glands diseases (Abdolrazaghnejad et al., 2019). The two tests would help determine or rule out the possibility of gastroenteritis and diverticulitis.
I would reject the diagnosis of gastroenteritis because of inadequate objective and subjective data. Today, abdominal pain is a leading cause of litigation due to the inappropriate diagnosis of gastroenteritis (Medford et al., 2016). The physical exam findings in the abdominal assessment are not supportive of the diagnosis. A left lower quadrant abdominal pain for 3-4 days is highly suggestive of diverticulitis than gastroenteritis. Diverticulitis is characterized by inflamed or infected pouches in the intestinal lining (Medford et al., 2016). Patients present with pain on the left lower quadrant due to the involvement of the sigmoid colon. Other symptoms include diarrhea and lower abdominal tenderness. Gastroenteritis is mostly associated with nonfocal abdominal pain and cramping due to the irritation and inflammation of the stomach lining (Duncan, 2018). The findings of the abdominal exam are more suggestive of a diverticulitis diagnosis than gastroenteritis.
Irritable bowel disease (diarrhea predominant) is a possible diagnosis for the patient. The condition presents with abdominal pain and diarrhea consistent with the patient's symptoms. However, additional subjective data about the behavior of diarrhea would help provide more information towards the diagnosis. Patients with IBS often have a sudden and irresistible urge to defecate, mucus in stool, and a feeling of incomplete defecation. Although nausea is not specific for all patients, IBS would be a credible differential diagnosis.
Abdolrazaghnejad, A., Rajabpour-Sanati, A., Rastegari-Najafabadi, H., Ziaei, M., & Pakniyat, A. (2019). The Role of Ultrasonography in Patients Referring to the Emergency Department with Acute Abdominal Pain. Advanced journal of emergency medicine, 3(4).
Asif, T., Mohiuddin, A., Hasan, B., & Pauly, R. R. (2017). Importance of thorough physical examination: a lost art. Cureus, 9(5). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5453739/
Duncan, D. L. (2018). Gastroenteritis: An overview of the symptoms, transmission, and management. British Journal of School Nursing, 13(10), 484-488.
Kasırga, E. (2019). The importance of stool tests in diagnosis and follow-up of gastrointestinal disorders in children. Turkish Archives of Pediatrics/Türk Pediatric Arşivi, 54(3), 141.
Medford-Davis, L., Park, E., Shlamovitz, G., Suliburk, J., Meyer, A. N., & Singh, H. (2016). Diagnostic errors related to acute abdominal pain in the emergency department. Emergency Medicine Journal, 33(4), 253-259.
Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK482263/
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