Assessment of the Abdomen and Gastrointestinal System 

Further Information on Documentation

Substance Portion

The patient’s recent dietary habits, specifically any recent changes in diet or new foods consumed, as well as any recent travel history or exposure to sick individuals should be documented. The patient’s usual bowel habits, frequency, consistency and color of stools, as well as any changes in these should also be recorded. Note any other symptoms that may accompany the bowel problems, including fever, nausea, or weight loss.

Objective Portion

The patient’s abdominal examination should be further detailed by recording the location, intensity, and character of the pain, as well as any rebound tenderness, guarding, or masses felt on palpation. Documentation should be made of the presence of hepatosplenomegaly or jaundice as well as visible peristalsis. Rectal examinations should be performed to determine if there is blood or mucous present in the stool.

Assessment:

Both subjective and objective data support the diagnosis of gastroenteritis, as the patient reported nausea, diarrhea and generalized abdominal discomfort. Physical examination revealed hyperactive sounds in the bowel and tenderness on the lower left quadrant. These are all signs of gastroenteritis.

The Right Diagnostic Tests for Diagnosis

You can perform a stool analysis to determine if there are any pathogens, such as bacterial, viral or parasitic, that cause gastroenteritis. A blood test can be performed to determine electrolyte levels and any signs of an infection. A CT or abdominal ultrasound may be ordered to check for any abnormalities of the digestive tract.

The current diagnosis of gastroenteritis is acceptable given the patient’s symptoms and physical exam findings.

Differential Diagnosis

1. IBD (Inflammatory Bowel Disease): IBD is characterized by symptoms like chronic diarrhea, abdominal discomfort, and loss of weight. The condition can be caused by inflammation of the gastrointestinal tract. It is diagnosed with colonoscopy or biopsies.
2. Diverticulitis – Diverticulitis can be characterized as an inflammation or infection in pouches of the colon. It may cause abdominal pain, nausea and vomiting. This condition is diagnosed using a CT scan.
3. Irritable Bowel Syndrome: IBS is characterized by symptoms like abdominal pain, swelling, and changes to bowel habits. The condition is diagnosed by observing symptoms and ruling other possible causes out.

References:

1. Crohn’s and Colitis Foundation. (2022). Inflammatory bowel diseases. Retrieved From https://www.crohnscolitisfoundation.org/what-is-ibd
2. Mayo Clinic. (2021). Diverticulitis. Taken from https://www.mayoclinic.org/diseases-conditions/diverticulitis/symptoms-causes/syc-20371758
3. American College of Gastroenterology (2022). Irritable bowel syndrome. Retrieved From https://gi.org/topics/irritable-bowel-syndrome/