Assignment 1: Lab Assignment: Assessing the Abdomen

Assignment 1: Lab Assignment: Assessing the Abdomen

Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen

The SOAP note is about a 47-year-old male with abdominal pain and diarrhea. He has had generalized for three days but has not taken any meds to relieve the pain. He reports that the pain was initially at 9/10 but has reduced to 5/10, and he cannot eat due to ensuing nausea. His medical history is positive for hypertension, DM, and GI bleeding. Examination of the abdomen reveals a soft abdomen, increased bowel sounds, and LLQ pain. The purpose of this assignment is to examine the SOAP note and discuss pertinent diagnostic tests and differential diagnoses.

Don't use plagiarized sources. Get Your Custom Essay on
Assignment 1: Lab Assignment: Assessing the Abdomen
From $8/Page
Order Essay

Subjective Portion

The HPI should have given an additional description of the abdominal pain, particularly the duration of the abdominal pain, timing (before, during, or after meals), and frequency. In addition, it should describe the pain’s characteristics, for example whether it is crampy, piercing, dull, colicky, radiating, diffuse, or stable (Sokic-Milutinovic et al., 2022). In addition, the HPI should have included the exacerbating and alleviating factors for the abdominal pain and to what level the alleviating factors relieve the pain. Furthermore, the HPI has described only the abdominal pain leaving out diarrhea. It should describe diarrhea, including the onset, timing, frequency, characteristics of the stools (watery, mucoid, bloody, greasy, or malodorous), and relieving and aggravating factors.

The subjective part should have included the patient’s immunization status with a focus on the last Tdap, Influenza, and COVID shots and surgical history. The social history has scanty information and should have included the patient’s education level, occupation, current living status, hobbies, exercise and sleep patterns, dietary habits, and health promotion interventions (Gossman et al., 2020). Lastly, a review of systems (ROS) is mandatory for a SOAP note. Thus, the SOAP note should have a ROS that indicates the pertinent positive and negative symptoms in each body system, which helps identify other symptoms the patient has not reported in the HPI.

Objective Portion

The objective part misses critical information like the findings from the general assessment of the patient, which should include the client’s general appearance, personal hygiene, grooming, dressing, speech, body language, and attitude towards the clinician. Moreover, the objective part should have physical exam findings from a focused abdominal exam. This includes findings from abdominal inspection, such as the pigmentation, symmetry, respiratory movements, contour, and visible masses. Additional auscultation findings that should be indicated include the presence of friction ribs, vascular sounds, and venous hum. It should also have exam findings from palpation and percussion, including abdominal tenderness, masses, organomegaly, guarding, or rebound tenderness (Sokic-Milutinovic et al., 2022). Besides, the liver span and spleen position should be indicated.

Assessment

The listed assessment findings are LLQ pain and gastroenteritis (GE). LLQ pain is supported by subjective findings of abdominal pain and LLQ tenderness on exam. GE is supported by symptoms of abdominal pain, diarrhea, and nausea and exam findings of low-grade fever and increased bowel sounds.

Diagnostic Tests

The diagnostic tests that should be ordered for this patient include stool culture, complete blood count (CBC), and abdominal ultrasound. A stool culture is crucial to look for ova and cyst, which will help establish the causative agent for diarrhea and guide the treatment plan. Based on the WBC count, the CBC will establish if the patient has an infection and if the infection is bacterial or viral (Sokic-Milutinovic et al., 2022). The abdominal ultrasound will be used to visualize abdominal organs and identify if there is inflammation that could be contributing to the patient’s GI symptoms.

Differential Diagnoses

GE is an acceptable diagnosis since the patient has classic symptoms of abdominal pain, diarrhea, nausea, mild fever, increased bowel sounds, and abdominal tenderness. Nevertheless, I would reject LLQ pain as a diagnosis because it is a physical exam finding and does not fit the description of a medical diagnosis. The likely diagnoses for this case are:

Acute Viral Gastroenteritis

Viral GE is a self-limiting diarrheal disorder attributed to infection by viruses. The common causative viruses arerotavirus, norovirus, enteric adenovirus, and astroviruses. Patients present with nausea, anorexia, vomiting, diarrhea (watery), abdominal pain and tenderness, mild fever, dehydration, and increased bowel sounds (Orenstein, 2020). Thus, Viral GE is a differential diagnosis owing to the patient’s nausea, abdominal pain, diarrhea, mild fever, increased bowel sounds, and abdominal tenderness.

Ulcerative Colitis (UC)

UC is a chronic inflammatory and ulcerative GI disorder that occurs in the colonic mucosa and is characterized by bloody diarrhea. Clinical symptoms include mild lower abdominal pain, bloody diarrhea, and bloody mucoid stools. Systemic manifestations include anorexia, nausea, fever, malaise, anemia, and weight loss (Porter et al., 2020). UC is a likely diagnosis due to positive findings of diarrhea, nausea, abdominal pain, and mild fever and the history of GI bleed.

Colonic Diverticulitis

Diverticulitis presents with inflammation of a diverticulum with the presence or absence of infection. Abdominal pain is the primary symptom of colonic diverticulitis. Patients present with LLQ abdominal pain and tenderness, which can sometimes be suprapubic and often have a palpable sigmoid. The abdominal pain is usually accompanied by fever, nausea, vomiting, and occasionally urinary symptoms (Swanson& Strate, 2018). Peritoneal signs like rebound and guarding can occur, especially with abscess or perforation. The patient’s nausea, mild fever, and LLQ pain makes Colonic diverticulitis a probable diagnosis.

Conclusion

The HPI in the objective portion should have described the characteristics of the abdominal pain and stated the onset, frequency, characteristics, and timing of diarrhea. A ROS should also be included with the patient’s positive and negative symptoms. The objective section should have comprehensive details of the abdominal exam findings. Diagnostic tests should include stool culture, CBC, and abdominal U/S. The likely diagnoses are Vital GE, Ulcerative colitis, and colonic diverticulitis.

References

Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing.

Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1

Porter, R. J., Kalla, R., & Ho, G. T. (2020). Ulcerative colitis: Recent advances in the understanding of disease pathogenesis. F1000Research9, F1000 Faculty Rev-294. https://doi.org/10.12688/f1000research.20805.1

Sokic-Milutinovic, A., Pavlovic-Markovic, A., Tomasevic, R. S., & Lukic, S. (2022). Diarrhea as a clinical challenge: General practitioner approach. Digestive Diseases40(3), 282-289.https://doi.org/10.1159/000517111

Swanson, S. M., & Strate, L. L. (2018). Acute colonic diverticulitis. Annals of Internal Medicine168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010

 

Calculate the price
Make an order in advance and get the best price
Pages (550 words)
$0.00
*Price with a welcome 20% discount applied.
Pro tip: If you want to save more money and pay the lowest price, you need to set a more extended deadline.
We know how difficult it is to be a student these days. That's why our prices are one of the most affordable on the market, and there are no hidden fees.

Instead, we offer bonuses, discounts, and free services to make your experience outstanding.
How it works
Receive a 100% original paper that will pass Turnitin from a top essay writing service
step 1
Upload your instructions
Fill out the order form and provide paper details. You can even attach screenshots or add additional instructions later. If something is not clear or missing, the writer will contact you for clarification.
Pro service tips
How to get the most out of your experience with Top Writers 4Me
One writer throughout the entire course
If you like the writer, you can hire them again. Just copy & paste their ID on the order form ("Preferred Writer's ID" field). This way, your vocabulary will be uniform, and the writer will be aware of your needs.
The same paper from different writers
You can order essay or any other work from two different writers to choose the best one or give another version to a friend. This can be done through the add-on "Same paper from another writer."
Copy of sources used by the writer
Our college essay writers work with ScienceDirect and other databases. They can send you articles or materials used in PDF or through screenshots. Just tick the "Copy of sources" field on the order form.
Testimonials
See why 10k+ students have chosen us as their sole writing assistance provider
Check out the latest reviews and opinions submitted by real customers worldwide and make an informed decision.
Healthcare Writing & Communications
Perfect! Thank you for also remembering to highlight the necessary words. Appreciate all of your help and hard work!
Customer 452483, November 7th, 2021
Nursing
Excellent! Thank you.
Customer 452487, October 16th, 2021
Healthcare Writing & Communications
Perfect! Thank you so much for all of your help!
Customer 452483, October 31st, 2021
Mathematics
Job WELL DONE! Thank You very much!!
Customer 452483, July 12th, 2021
Introduction to Sociology
Thank you very much for all of your hard work!
Customer 452483, October 15th, 2021
Nursing
Good job. Thank you
Customer 452487, September 16th, 2021
Group Dynamics
Great job. I appreciate it.
Customer 452521, November 22nd, 2021
Psychology
On point! Appreciate all the hard work!!
Customer 452483, August 16th, 2021
English 101
This writer was very quick with the draft and even faster with the revision! Thank you!
Customer 452603, May 30th, 2022
English 101
Perfect! Thank you so much for all of your hard work and help! Appreciate it!!
Customer 452483, August 30th, 2021
Psychology
Thank you so much for all of your hard work & help! It’s perfect! Appreciate it!!
Customer 452483, September 11th, 2021
Communications
Well done! I thank you very much!
Customer 452483, July 9th, 2021
1159
Customer reviews in total
96%
Current satisfaction rate
2 pages
Average paper length
47%
Customers referred by a friend
OUR GIFT TO YOU
20% OFF your first order
Use a coupon TOP20 and enjoy expert help with any task at the most affordable price.
Claim my 20% OFF Order in Chat