Abdominal Assessment Case Study SOAP Note

Nursing Homework Help| Nursing homework help

Analyse the subjective Portion

In the subjective part of the note, the patient states that he has abdominal pain which began three days ago. Today, he rates his pain at 5/10. However, it had been up to 9/10 in the past. He reports feeling nauseated and having diarrhea after eating. Documentation should include the duration and frequency of diarrhea as well as recent changes to diet or stress levels that may have contributed to symptoms.

Analyse the objective Portion

The objective portion of the note indicates that the patient’s vital signs are within normal limits, except for an elevated blood pressure of 160/86. In the abdominal assessment, there are hyperactive sounds of bowel and positive pains in the lower left quadrant. The documentation should also include information about the type and intensity of the pain and whether or not it is radiating to other parts. Also, any swelling and tenderness in the abdominal region can be noted.

Assessment:

Notes provide both subjective and objective data that support the diagnosis of gastroenteritis and pain in the left lower quadrant. Patient reports diarrhea and abdominal pain. The abdominal assessment shows hyperactive sounds and pain in the lower left quadrant.

Diagnostic Tests:

Diagnostic tests that may be appropriate for this condition include a stool culture, sensitivity test, complete blood counts (CBCs), an electrolyte profile, or imaging studies like a computed-tomography scan (CT) or abdominal ultrasound. These tests can be used for a diagnostic test to rule out any other condition and identify any structural or structurally abnormalities, as well as underlying infection, inflammation, etc.

Current Diagnosis

According to the information in the note the current diagnosis is gastroenteritis. However, other conditions need to be considered before the diagnosis can be confirmed. More information is needed to rule out other possible causes of the patient’s symptoms.

Differential diagnosis:

The differential diagnosis for this patient includes inflammatory colitis (IBD), diverticulitis and appendicitis. IBD causes abdominal pain, weight loss, and diarrhea. It is caused by chronic intestinal inflammation. Diverticulitis can be an inflammation or infection of the small pouches in the colon that cause pain in left lower quadrant, a fever and changes to bowel habits. Appendicitis, an inflammation of appendix, can cause pain in the right lower quadrant, nausea, and fever.

References:

1. Danese, S., & Fiocchi, C. (2011). Ulcerative Colitis. The New England Journal of Medicine. 365(18),1713-1725.
2. Peery, A. F., Sandler, R. S., Ahnen, D. J., Galanko, J. A., Holm, A. N., Shaukat, A., … & Burke, C. A. (2015). Constipation, low fiber diets and diverticulitis are not related. Clinical Gastroenterology and Hepatology. 13(2). 320-326.
3. Di Saverio, S., Birindelli, A., Kelly, M. D., Catena, F., Weber, D. G., Sartelli, M., … & Davies, R. J. (2017). WSES Jerusalem Guidelines for Diagnosis and Treatment of Acute Appendicitis. World Journal of Emergency Surgery. 12(1). 1-24.