Case Study: Assessing the Abdomen
Case Study: Assessing the Abdomen
In the accompanying SOAP note, the Caucasian female patient is 47 years old and has nausea, diarrhea, and widespread abdominal discomfort. The symptoms, according to the patient, began roughly three days ago. She also confirms a history of gastrointestinal bleeding that happened around four years ago but was successfully handled. The patient is now using diabetic and antihypertensive drugs to control his previous DM and HTN diagnoses. Denies using cigarettes but admits to consuming alcohol on occasion. A physical examination revealed that the patient’s discomfort originated in the left lower abdomen region. Hyperactive bowel noises are one of the physical symptoms. Based on these findings, the patient is diagnosed with gastroenteritis. The major purpose of this paper is to demonstrate an examination of the subjective and objective information presented and to arrive at the patient’s primary and differential diagnosis.
Subjective Data
The subjective information presented mostly highlights three basic symptoms shown by the patient: nausea, stomach discomfort, and diarrhea. Starting with abdominal discomfort, further information about its location and whether it has been growing worse or better is needed. The patient must also offer further details about the pain’s characteristics, such as throbbing or dull discomfort. Further information on nausea and diarrhea, including time and frequency, is also required for a thorough examination of the patient. The patient also reports diarrhea but fails to offer more information on the characteristics of her stool and bowel movement, which is critical for ruling out differentials (Stuempfig & Seroy, 2020). Additional information on the frequency, dose, and duration of usage of the individual medicines indicated is needed concerning the patient’s current medication. The information will aid in the promotion of good prescribing practices and the avoidance of hazardous medication responses. Other pertinent variables lacking from the offered subjective data are health promotion strategies such as food habits and physical exercise.
Objective Data
The objective data is extremely exact, however, there is insufficient information to further evaluate the patient’s principal complaint. A thorough physical examination from head to toe is essential for adult patients with comorbidities to determine that no other underlying ailment is contributing to the current symptoms. During a physical examination, the doctor discovered that the patient’s pain was coming from the left lower abdomen quadrant and was accompanied by hyperactive bowel noises. Building on these results, a thorough examination of the patient’s abdomen is required to look for bulges, hernias, swollen veins, or tumors (Pesek et al., 2019). Visual examinations are also required to determine whether the patient’s history of GI bleeding has been entirely resolved. Visual examinations are also required to determine whether the patient’s history of GI bleeding has been entirely resolved. The objective data also lack nutritional evaluation findings, which are critical in ruling out dietary reasons for the patient’s symptoms, such as food poisoning.
Assessment
The patient evaluation presented implies a diagnosis of gastroenteritis. The subjective and objective data both support the judgment, but not conclusively. Gastroenteritis is defined by GI disturbances such as diarrhea, stomach discomfort and nausea, and vomiting, all of which the patient experiences (Axelrad et al., 2019). Some important diagnostic characteristics, such as dysuria and infection symptoms, are lacking. As a result, the objective data show left lower quadrant stomach discomfort and hyperactive bowel noises, which are also seen in gastroenteritis patients. To confirm this diagnosis, however, stool investigation was required for culture and sensitivity tests to identify the causative infectious organisms.
Appropriate Diagnostic Tests
Patients who appear with GI symptoms such as diarrhea, stomach discomfort, and nausea, which are frequent in a variety of GI illnesses, require a thorough examination of the abdomen area to ensure an appropriate diagnosis. To begin, blood tests such as a complete blood count are required to rule out infections. For the adult patient in the case study, a rapid stool test was required to identify the causal pathogen, such as rotavirus or any other bacterium that might cause gastroenteritis (Osterwalder et al., 2020). Metabolic panel tests are also required to establish if the patient’s diabetes was adequately treated and how the patient’s obesity may be managed. CT scans and X-rays of the entire abdomen area are also required to rule out any deformities or abnormalities that may be causing the patient’s symptoms. Additional tests, such as PCR, are required for the diagnosis of calicivirus infection in the feces.
Current Diagnosis
The patient in the case study was diagnosed with gastroenteritis. The lab data does not fully support this diagnosis since information
indicating the causal bacterium is absent. Only the results of the stool test can confirm the diagnosis, thus it cannot be accepted at this time (Sharifi et al., 2022). As a result, the patient tested negative for infection-related symptoms such as fever and chills, which are critical in identifying individuals with gastroenteritis. As a result, the patient reported a history of GI bleeding, which is significant in determining the source of the patient’s current symptoms. As a result, additional investigation of the source of the patient’s GI bleeding and whether it is related to the current symptoms was required to rule out other probable causes such as intestinal obstruction, irritable bowel syndrome (IBS), and inflammatory bowel disease.
Differential Diagnosis
Inflammatory bowel disease (IBD), Irritable bowel syndrome (IBS), and intestinal obstruction (IO) are the 3 major differential diagnoses. Inflammatory bowel disease (IBD) is a broad term encompassing conditions characterized by persistent inflammation of the gastrointestinal system (Axelrad et al., 2019). The two most common kinds of IBD are ulcerative colitis and Crohn’s disease. This disease is characterized by decreased appetite, bloody stool, bloody urine, lethargy, stomach discomfort, and diarrhea. The patient has stomach discomfort and diarrhea. However, a stool test is required to confirm this diagnosis.
Irritable bowel syndrome (IBS) is a common gastrointestinal illness that affects the large intestine. Patients with IBS will experience gastrointestinal discomfort, diarrhea, cramps, bloating, and constipation (Sharifi et al., 2022). Because the patient has most of these symptoms, IBS is a plausible diagnosis. Upper endoscopy and colonoscopy, however, are required to confirm this diagnosis.
Finally, intestinal obstruction (IO) is defined as a considerable physical impediment of the intestinal tract caused by a pathological disease that results in bowel obstruction (Osterwalder et al., 2020). Cramping, stomach discomfort, a lack of flatus, and constipation are all symptoms of this condition. An X-ray of the colon, however, is required to confirm this diagnosis.
Case Study: Assessing the Abdomen References
Axelrad, J. E., Olén, O., Askling, J., Lebwohl, B., Khalili, H., Sachs, M. C., & Ludvigsson, J. F. (2019). Gastrointestinal Infection Increases Odds of Inflammatory Bowel Disease in a Nationwide Case–Control Study. Clinical Gastroenterology and Hepatology, 17(7), 1311-1322.e7. https://doi.org/10.1016/j.cgh.2018.09.034
Osterwalder, I., Özkan, M., Malinovska, A., Nickel, C. H., & Bingisser, R. (2020). Acute Abdominal Pain: Missed Diagnoses, Extra-Abdominal Conditions, and Outcomes. Journal of Clinical Medicine, 9(4), 899. https://doi.org/10.3390/jcm9040899
Pesek, R. D., Reed, C. C., Muir, A. B., Fulkerson, P. C., Menard-Katcher, C., Falk, G. W., Kuhl, J., Martin, E. K., Magier, A. Z., Ahmed, F., Demarshall, M., Gupta, A., Gross, J., Ashorobi, T., Carpenter, C. L., Krischer, J. P., Gonsalves, N., Spergel, J. M., Gupta, S. K., & Furuta, G. T. (2019). Increasing Rates of Diagnosis, Substantial Co-Occurrence, and Variable Treatment Patterns of Eosinophilic Gastritis, Gastroenteritis, and Colitis Based on 10-Year Data Across a Multicenter Consortium. The American Journal of Gastroenterology, 114(6), 984–994. https://doi.org/10.14309/ajg.0000000000000228
Sharifi, M., Safarpour, A. R., Barati-Boldaji, R., Rahmati, L., Karimi, S., & Bagheri Lankaran, K. (2022). Post-Infectious Irritable Bowel Syndrome after an Epidemic of Gastroenteritis in South of Iran. Middle East Journal of Digestive Diseases, 14(3), 304–309. https://doi.org/10.34172/mejdd.2022.287
Stuempfig, N. D., & Seroy, J. (2020). Viral Gastroenteritis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK518995/