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.

Assignment 1 for Week 6 of NURS 6512: Advanced Health Assessment and Diagnostic Reasoning at Walden University| NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning | Walden University

Further Information on Documentation

Subjective:

• How often, how much, and what color is diarrhea?
• Type of foods consumed prior to and following the onset or pain
• There is a correlation between nausea, vomiting and frequency.
• Pain intensity and duration
• The patient’s medical history related to gastrointestinal disorders
• Medication that could cause gastrointestinal symptoms

Objective:

• The symptoms of abdominal pain
• Complete abdominal evaluation, including the four quadrants
• The stool, its appearance and the presence of blood
• Information on the patient’s hydration status
• Dry mucous membranes or sunken eyes are signs of dehydration
• The results of other diagnostic tests

This assessment can be supported both by subjective and object information, since the patient complains of pain in the left lower quadrant and is making hyperactive sounds with his bowels. These symptoms indicate that gastrointestinal issues may exist.

Tests that can be used to diagnose this condition include:

• Sample stool for culture and sensitivity
• Check for inflammation with a blood test
• Check for structural abnormalities with abdominal ultrasound
• Colonoscopy for colon and rectum examination
• The abdomen and pelvis scanned

The current diagnosis is hard to accept without more testing because there are a number of conditions that can produce similar symptoms. Three conditions may be included in the differential diagnosis of this patient.

• Inflammatory Bowel Disease (IBD).
• Diverticulitis
• Irritable bowel syndrome (IBS)

IBD can be characterized as chronic inflammation in the digestive tract. It may cause abdominal pain and diarrhea. Diverticulitis can result in abdominal pain and diarrhea. IBS, or functional gastrointestinal disorders, can lead to abdominal pain, bloating and changes in bowel habit.

References:

• Ignjatovic, A., & Saunders, Y. (2019). (2019). Surgery (Oxford), 37(3), 145-151. doi: 10.1016/j.mpsur.2018.12.005
• Peery, A. F., Keku, T. O., & Martin, C. F. (2019). Diverticulitis, its natural history and risk factors: An epidemiological review. Clinical Colon and Rectal Surgery, 32(3), 157-163. doi: 10.1055/s-0039-1688496
• Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable Bowel Syndrome: A Clinical Review. Journal of the American Medical Association, 313(9), 949-958. doi: 10.1001/jama.2015.0954