Abdominal Assessment (Essay Sample)

Abdominal Assessment Name of Author Institutional Affiliation Abdominal Assessment Patient Information: Initials: JR Age: 47Sex: MaleRace: Caucasian S. 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) O. 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, hyperctive bowel sounds, pos pain in the LLQ Diagnostics: None A. Differential Diagnoses: Left lower quadrant pain, Gastroenteritis Analysis of the Subjective Portion When treating a patient who complains of generalized abdominal pain, it is vital to gather all the information about their subjective history regarding the pain so as to make a well informed differential diagnoses (Ball et al., 2015). In this case, the subjective analysis can be expounded by using more targeted questions. That way, it will be possible to get a detailed account of the pain the patient is feeling. A comprehensive subjective history of a patient’s illness places the practitioner at a better position of making the right judgment before the completion of the diagnostic test (Dains, Baumann, & Scheibel, 2016). When talking about the pain, the patient mentions that it started three days ago. To get more details about the pain and to establish what led to its onset, the practitioner should inquire about how it began. Did it start suddenly or was it gradual? What activity was the patient partaking before the onset? How bad is the pain on a scale of 1 to 10? Is it stabbing, sharp, or aching? Establishing the quality and type of pain the patient is experiencing can play a huge role in identifying the problem. For instance, if they describe a colicky ache, you will start thinking about forceful peristaltic contractions. On the other hand, a poorly localized pain is mostly related to visceral peritonitis (Ross, Matthay, & Harris, 2018). When dealing with a case of abdominal pain, asking about the patient’s bowel movements is important (Dains et al., 2016). You must establish the frequency, the consistency, the characteristics, the smell and color (Ball et al., 2015). These things tell more about the processes that are taking place in the bowel. For instance, if the patient describes a frequent diarrhea that is loose and has a strong smell, it can be Helicobacter pylori (H. Pylori) (Malfertheiner et al., 2017). In this scenario, the practitioner would have to recommend a stool test to check if it contains the bacterium. The patient can also be asked about their history with GI bleed to collect information about past GI tract disorders and procedures. Analysis of the Objective Portion Considering the abdominal assessment, the objective assessment in the case is adequate. However, assessments like measuring the abdominal girth to check if it is enlarged and percussing it to see if it is distended could provide more insight (Ball, et al., 2015). Is the assessment supported by the subjective and objective information? The subjective information provided supports the assessment. The temperature, the blood pressure and heart rate of the patient have elevated slightly as a result of the pain that they are feeling. The hyperactive sounds in the bowel correlate with the patient’s description of experiencing diarrhea. The tenderness being felt in the left lower quadrant (LLQ) differs from the initially described generalized pain. Nonetheless, it could be the focal point of the pain (Dains et al., 2016). Diagnostic tests for this case To collect the diagnostic data that is needed for this case, I would begin by requesting several tests to eliminate the possibility of an infection, parasitic infections or electrolyte imbalances which could be contributing to the pain. These would involve a complete metabolic panel (CMP), a complete blood count (CBC), Phosphate, Magnesium, clostridium difficle stool (C. Diff) and occult stool (Leblond et al., 2014). If there is a high white count, that would indicate the presence of an infection and more tests would need to be done to identify its source. The CMP would indicate kidney, liver and electrolyte function. Electrolyte imbalances can occur due to excessive diarrhea which will, in turn, lead to peristalsis changes causing abdominal pain. An occult stool would check if the person is experiencing intestinal bleeding (Leblond et al., 2014). The C. Diff would eliminate the probability of a Pylori infection. A CT abdomen would provide imaging to decide if the patient needs any surgical interventions. If the CT is not available, an LLQ ultrasound and an abdominal x-ray would help to visualize the specific section (Leblond et al., 2014). Because of the GI bleed history, it would be appropriate to perform an Esophagogastroduodenoscopy (EGD) based on what is discovered in the occult stool test. Is the Current Diagnosis Acceptable? The current diagnosis is acceptable since in his description, the patient describes symptoms that are similar to those of gastroenteritis; nausea, diarrhea and generalized abdominal pain. The elevation in the patient’s temperature also indicates the condition. However, the tenderness does not specifically indicate gastroenteritis, and I would, therefore, have to order a CT or an LLQ US to eliminate the probability of other processes taking place. Conditions That Could Be Considered a Different Diagnosis Ulcerative Colitis Because of the GI bleed history, the patient might be suffering from ulcerative colitis (UC). The described symptoms, the temperature rise and presence of diarrhea qualify it to be a differential diagnosis. Quantification through the use of mass spectrometry and protein identification differentiate ulcerative colitis from other conditions involving bowel inflammati...