Abdominal Assessment Case Study
Abdominal Assessment Case Study
The SOAP Note depicts the case of JR, a 47-year-old White male with complaints of generalized abdominal pain and diarrhea. The SOAP note includes the patient’s subjective history, objective portion, and assessment findings. The assessment portion includes Left lower quadrant pain and Gastroenteritis. This paper seeks to analyze the SOAP note, explain appropriate diagnostic tests, and the differential diagnoses for this case.
The subjective portion contains the chief complaint, history of present illness (HPI), past medical history (PMH), allergies, family history, and social history. The HPI describes the chief complaint of abdominal pain, including the onset, location, associated symptom, and pain severity. Additional information is needed on the duration of each pain episode, characteristics of the pain, aggravating factors, and relieving factors (Gossman, Lew & Ghassemzadeh, 2020). The HPI should describe if the abdominal pain is sharp, crampy, colicky dull, constant, or radiating. It should also have information on the time of the day when the pain is most severe.
Additional information is needed on diarrhea symptoms; including its onset, frequency, stool characteristics such as consistency, and volume, aggravating factors, and related symptoms such as tenesmus (Gossman et al., 2020). Information on stool characteristics should describe if the stool is mucoid, watery, bloody, greasy, frothy, or foul-smelling and the color of stools. Furthermore, the HPI should provide information on food ingestion history, water exposure, travel history, and predisposing conditions.
The PMH provides information on the patient’s medical history, including chronic illnesses such as hypertension, Diabetes, and GI bleed that occurred four years ago. It should have included additional information on the year of diagnosis of diabetes and hypertension and state if the patient has adequately controlled blood pressure and glucose. Additional information is needed on the frequency that the patient takes Lisinopril, Amlodipine, and Metformin.
The social history provides information on the patient’s tobacco and alcohol use and marital status. However, it should include additional information on his living environment, major hobbies, education status, source of income, health promotion activities, and safety measures taken by the patient (Gossman et al., 2020). The subjective history should have also included the patient’s surgical history, traumatic injuries, and current immunization status (Gossman et al., 2020). Besides, a review of all systems should be included in the subjective portion, identifying symptoms affecting other body systems not mentioned in the HPI.
The objective portion includes vital signs, anthropometric measurements, and physical exam findings from the assessment of the lungs, heart, skin, and abdomen. However, it should have provided information on the general examination findings. This includes the patient’s general health status, grooming, dressing, mannerism, eye contact, and speech. The focused abdominal assessment should also provide detailed information on the normal and abnormal findings from a comprehensive exam of the abdomen. For example, it should have information on the liver span and location of the spleen from the left coastal margin to determine if there is hepatosplenomegaly. Additionally, it should indicate the presence or absence of palpation findings such as abdominal masses, muscle guarding, muscle spasm, or rebound tenderness.
The assessment findings in the SOAP note include Left lower quadrant (LLQ) pain and Gastroenteritis. LLQ is supported by objective findings of pos pain in the LLQ. However, it is not consistent with subjective history since the HPI describes the abdominal pain as generalized. Gastroenteritis is supported by the subjective history of diarrhea and abdominal pain as well as objective findings of hyperactive bowel sounds.
Appropriate diagnostic tests for this patient include Ultrasonography of the abdomen, stool microscopy, stool culture, and leukocyte count. Ultrasonography is appropriate to determine the presence of organ enlargement or inflammation, which could be the cause of abdominal pain (Gans et al., 2015). Stool microscopy will be used to examine for ova and parasites to determine if the diarrhea is caused by protozoa (Nemeth & Pfleghaar, 2020). Stool culture will be important to determine the cause of diarrhea such as Salmonella, Shigella, C.difficile, E.coli, Vibrio, or Y.enterocolitica (Nemeth & Pfleghaar, 2020). Leukocyte/ WBC count will determine if the patient has inflammation or infection, causing abdominal pain (Gans et al., 2015). It will also determine the causative pathogen for diarrhea if it is viral or bacterial.
I would reject the diagnosis of LLQ pain since pain is not considered a diagnosis but a clinical symptom that guides the diagnosis. I would accept Gastroenteritis as a diagnosis since the subjective and objective findings support the diagnosis, including diarrhea, abdominal pain, nausea, and hyperactive bowel sounds. Differential diagnoses for this case can include:
Gastroenteritis refers to an infectious disease of the GI tract. It is caused by one or more bacterial, viral, or protozoa pathogens causing structural or functional damage of variable degree and severity to the mucosa (Desselberger, 2017). Viruses are the causative pathogens in viral Gastroenteritis. The viruses include Rotavirus, Adenovirus, and Astrovirus. Viral Gastroenteritis results in a self-limited watery diarrheal illness that lasts less than one week. Its most common symptoms are acute vomiting and diarrhea. Associated symptoms include nausea, anorexia, malaise, and fever (Desselberger, 2017). Physical exam findings include slightly elevated temperature, weight loss, dry mucous membrane, hyperactive bowel sounds, and mild abdominal tenderness (Desselberger, 2017). Viral Gastroenteritis is a differential diagnosis based on pertinent positive findings of abdominal pain, diarrhea, nausea, low-grade fever of 99.8F, hyperactive bowel sounds, and abdominal tenderness on palpation.
Acute diarrhea is characterized by an abrupt onset of three or more loose stools per day and lasts no longer than 14 days. Signs and symptoms of diarrhea include abdominal pain or cramping, perianal erythema, vomiting, abdominal bloating, flatulence, fever, and bloody or mucoid stools (Drancourt, 2017). Patients present with Borborygmi or increased peristaltic activity and signs of dehydration, such as dry mucous membranes, sunken eyes, poor skin turgor, and delayed capillary refill (Drancourt, 2017). Acute diarrhea is a differential diagnosis based on pertinent positive findings of passing frequent loose stools, abdominal pain, and hyperactive bowel sounds.
Clinical features of Acute diverticulitis include fever, left lower quadrant pain, and change in bowel habits, either diarrhea or constipation. Left lower abdominal pain is the most common symptom in 70% of patients (Rezapour, Ali & Stollman, 2018). The abdominal pain is mostly described as crampy and is associated with a change in bowel habits. Other symptoms include nausea, vomiting, flatulence, constipation, and bloating (Rezapour et al., 2018). Acute diverticulitis may be due to complications, such as intestinal perforation, colonic abscess, or fistula formation (Rezapour et al., 2018). Acute diverticulitis is a differential diagnosis based on pertinent positive findings of left lower quadrant pain, diarrhea, nausea, and elevated body temperature.
The subjective portion should include additional information that describes the duration, characteristics, aggravating, and alleviating factors of abdominal pain and diarrhea. It should also include the immunization status, frequency of current medications, surgical history, and detailed social history. The SOAP note’s objective portion should have additional information on the general exam findings and detailed abdominal exam findings. Appropriate diagnostic tests for this patient include Ultrasonography of the abdomen, stool microscopy, stool culture, and leukocyte count. The differential diagnoses based on the patient’s subjective history and objective findings include viral Gastroenteritis, Acute Diarrhea, and Acute Diverticulitis.
Desselberger, U. (2017). Viral Gastroenteritis. Medicine (Abingdon, England: UK ed.), 45(11), 690–694. https://doi.org/10.1016/j.mpmed.2017.08.005
Drancourt, M. (2017). Acute Diarrhea. Infectious Diseases, 335–340.e2. https://doi.org/10.1016/B978-0-7020-6285-8.00038-1
Gans, S. L., Pols, M. A., Stoker, J., Boermeester, M. A., & Expert Steering Group. (2015). Guideline for the diagnostic pathway in patients with acute abdominal pain. Digestive Surgery, 32(1), 23-31. https://doi.org/10.1159/000371583
Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing.
Nemeth, V., & Pfleghaar, N. (2020). Diarrhea. StatPearls [Internet].
Rezapour, M., Ali, S., & Stollman, N. (2018). Diverticular Disease: An Update on Pathogenesis and Management. Gut and liver, 12(2), 125–132. https://doi.org/10.5009/gnl16552
•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) but will be required for future courses.
The Assignment Instructions
Do this assignment in narrative form and not SOAP note form. Please follow the rubric.
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.
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