NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen

NURS 6512 Week 6 Assignment 1: Lab Assignment: Assessing the Abdomen

NURS 6512 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 abdominal pain 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.

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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 complete blood count (CBC) stool culture, 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 include 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. F1000Research, 9, 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 Diseases, 40(3), 282-289.https://doi.org/10.1159/000517111

Swanson, S. M., & Strate, L. L. (2018). Acute colonic diverticulitis. Annals of Internal Medicine, 168(9), ITC65–ITC80. https://doi.org/10.7326/AITC201805010