Case study Week 6- Assessment of the Abdomen and Gastrointestinal System

Assessment of the Abdomen and Gastrointestinal System

The following report will examine a SOAP note contextual investigation of a 47 years old male that reveals generalized abdominal pain among other side effects. To do this, the paper is going to analyse the patient’s subjective and objective data as introduced and come up with additional information that should be incorporated in the SOAP segment. There will also be current literature and analytical tests that will be evaluated as part of the important information from the patient where various determinations are going to be discussed and data which support or reject each assessment. 

Analysis of the Subjective Data

Based on the subjective data of the patient, it can be revealed that the patient’s history with the present illness is not clear and there is a need to look for more data. The clinicians must look for the ineffectiveness of limited, dull, or aching pain that is developed due to instinctively innervated organs that are contrasted to the distinctively 'sharp'.  It is also evident from the subjective data that the patient is experiencing generalized pain, however, he does not know the trigger (Natesan et al., 2016).  Among the common components is the reaction to eating. Also, it is important to look at evidence of any emesis which the patient could be having and information regarding the solid bowel movement or if there are traces of stool in the blood.  Any trace of it could help reveal if the patient is suffering from the gastrointestinal tract.  It is also important to look at the patient's diet and when he last ate, this can be done through conducting a 24-hour review of his diet and whether he introduced anything strange in his meal as this could have aggravated the gastrointestinal tract.  It is also important to know whether he might have travelled to another region as this would result in protozoal contamination (Miller & Alpert, 2006). Also, the patient's past medical history was very important as it showed that he experienced a bleed four years ago. It would also be important to find out whether he was hospitalized in the process and whether the reason for hospitalization as gastrointestinal bleed.  Also whether he was performed a surgical procedure like colonoscopy or GI. 

Analysis of Objective Data

Objective data includes reviewing the patient vital signs which could reveal the potential shock and provide information regarding the current patient's clinical status.  From the subjective data, it is evident that the patient's temperature is low grade, and his blood pressure is hoisted which could be caused by the blood pressure regimen resistance.  It would also be important to look at the skin color, capillary refill, and mucous membrane including the patient's eyes to assess if he is also dehydrated.  It would also help if the abdominal assessment looked at both quadrants, especially if the left lower quadrant show signs of organomegaly on palpation (Madgaonkar, 2011). It is also important to look at whether the area in the patient's stomach was rounded or flat, also one should look at other regions with discoloration, also due to the size of the patient it is possible that the stomach area is going to be standard.  Distention also means fluid, gas, or ascites presence, especially if it happens to relate to the averted umbilicus.  The auscultation also looks at the constrained symptomatic utility, where if prolonged could lead to bowel sounds which leads to ineffective use of time and the one experienced with abdominal fiasco or ileus.  

 

3. Whether the assessment is supported with subjective or Objective Information

The assessment reveals a left lower quadrant discomfort and gastroenteritis. In this way, it can be said that the assessment is supported with objective information which shows the left lower quadrant torment from derived from the physical examination and the various conclusion on gastroenteritis (Madgaonkar, 2011). However when it comes to the subjective data, it can be concluded there are no essential areas related to the SOAP note (Avegno & Carlisle, 2016).  The need to include lab tests, diagnostics, current co-morbidities, differential determination to come up with complete analysis. It is also important to clarify assessment information which is required in the incorporation of all the essential body areas to provide objective or subjective proof. 

Appropriate Diagnostic Tests

Based on the SOAP note, the diagnostic tests should also include a Complete Blood Count, Basic Metabolic Panel, Stool culture, CT exam, and X-ray.    The complete Blood count test is appropriate because the patient reports a past with a gastrointestinal bleed, this will be important to determine whether the patient is likely to experience   GI bleed again and provide a suitable treatment plan (Madgaonkar, 2011).  Also conducting a Basic Metabolic Panel test can help in the provision of an exact picture of the electrolyte status of the patient.  Based on the fact that the patient is diabetic, it means that his renal capacity matters a lot, the blood urea nitrogen, and the level of sugar which can lead to dehydration.  Because the patient has also had abnormal bowel, this could lead to liquid exhaustion leading to a possible Hypernatremia (Natesan et al., 2016).  Also conducting stool tests and culture would reveal if there is blood in the stool which could mean gastrointestinal bleeding, latex agglutination, or chemical immunoassay for infections. This would reveal evidence for gastroenteritis by conducting immunofluorescence examination, serology, microscopy, and checking for viral culture. By completing a stool culture for parasites and ova reveals parasitic or bacterial etiology (Natesan et al., 2016).  It will also help to conduct abdominal radiography, though it is at times a challenge for patients with abdominal pain due to the absence of added value on top of general evaluation. 

Three conditions as a differential diagnosis

1. Viral Gastroenteritis

 

This is a condition that is most common in the patient’s digestive organs which when diagnosed it means that the individual will experience watery looseness of the bowel, accompanied by pain or periods like cramping in the patient’s abdomen, vomiting or queasiness and irregular forms of fever (Madgaonkar, 2011).  According to various diagnostic studies, viral gastroenteritis will also incorporate around three sessions of watery stool within 24 hours which also is an indication that the patient is going to endure the same in the coming 7 days.  This is also incorporated with other conditions such as vomiting, queasiness, spasms, and pain in the abdomen, loose stools, and spasms and mucous or blood in the patient stools (Natesan et al., 2016).  All these data are helpful and reveals that the patient could have viral gastroenteritis because the patient is said to have a fever, stomach pain, queasiness, and loose stools. It is also revealed from the subjective data and HPI that his discomfort continued to reduce in the past days but was accompanied by side effects/ also symptomatic test are dependent on clinical introduction, also, because the patient revealed the side effects of loose stools it means that blood tests should be conducted to guarantee electrolyte position as relevant and that there is little evidence regarding loss.  

 

2. Bowel Obstruction of Large Intestines

After analyzing the patient's subjective data by looking at the obstruction area, there is likely going to be rigidity and distention. It could also be revealed that the patient bowel sounds are missing or hypoactive, the pain is also steady with an increment of profound breathing, coughing, and movement (Madgaonkar, 2011). In other words, there could be no proof of the idea that the patient is in respiratory trouble based on the evidence of the respiratory rate of 16 in addition to the target information the chest symmetry and clarity of the lungs.  The acknowledgment of the gastric outlet and the hindrance on the extensive intestine on the patient that is generally sound or one with an initial growth history can also lead to the questions as to whether there is a repetitive condition or one that is still to be discovered. Based on the SOAP results of the patient it shows that the patient has extraordinary abdominal sounds, indicating that her belly is delicate; however, there is also no subjective data show that that the patient is an experience enhanced discomfort with the motion.  Indication of the hindrance of trademarks includes colicky discomfort and the disability to excrete or pass flatus within 24 hours (Avegno & Carlisle). It is important to assess the renal capacity of the patient to check whether there is blood in the urine which could also mean dehydration or kidney disappointment. Serum amylase is also common for patients with abdominal conditions. 

3. Gastritis

Gastritis is about typical bacterial contamination which can also lead to various serious abdominal conditions.  Clostridium Welchii is also viewed as being one of the destructive agents like the use of alcohol or smoking.  According to patient history, he revealed the periodic use of ETOH. The constant use of alcohol is also another cause for gastritis because it leads to the destruction of sulfhydryl mixes in the gastric mucosa.  Also the Helicobacter pylori contamination can be related to the abuse of other anti-inflammatory medications including ETOH. Based on the subjective and objective information of the patient, it was evident that the patient does not abuse alcohol (Madgaonkar, 2011).  Also based on family history, there is no history of a person with gastritis of H pylori condition.  Other side effects of gastritis would include early satiety, iron deficiency, and unexplained reduction of the individual weight, continuous vomiting, and dysphagia.  To check whether the patient has gastritis this will perform a fecal antigen test to reveal H pylori antigen which has less than 90% affectability (Madgaonkar, 2011). 

Conclusion

This assessment report provided a SOAP note analysis of a patient's abdomen and gastrointestinal system revealing the presence of gastroenteritis.  It is important however to make improvements on the patient's subjective and objective data to include the areas mentioned through conducting more analytical tests and can help improve this information.  The report also discussed different findings and alternative diagnoses which is fundamental in establishing a contextual assessment and treatment of patient conditions. 

 

 

References

Avegno, J., & Carlisle, M. (2016). Evaluating the patient with right upper quadrant abdominal pain. Emergency Medicine Clinics of North America, 34(2), 211-228. https://doi.org/10.1016/j.emc.2015.12.011

Madgaonkar, C. (2011). Abdominal pain. Diagnosis: A Symptom-based Approach in Internal Medicine, 7-7. https://doi.org/10.5005/jp/books/11229_2

Miller, S. K., & Alpert, P. T. (2006). Assessment and differential diagnosis of abdominal pain. The Nurse Practitioner, 31(7), 38??? 47. https://doi.org/10.1097/00006205-200607000-00008

Natesan, S., Lee, J., Volkamer, H., & Thoureen, T. (2016). Evidence-based medicine approach to abdominal pain. Emergency Medicine Clinics of North America, 34(2), 165-190. https://doi.org/10.1016/j.emc.2015.12.008

R, N. (2007). The differential diagnosis of abdominal pain. Practical Gastroenterology, 36-36. https://doi.org/10.5005/jp/books/10649_5