Abdomen and Gastrointestinal System Essay.
Case study assessment;
Subjective Data: Chief complaint: ‘My stomach hurts, I have diarrhea and nothing seems to help”.
History of present illness(HPI): JR, 47 Year-old complains of having generalized abdominal pain that persist without medications because he did not know what to take.He states the pain is 9/10 when it first started.He has been able to eat with some nausea after.Abdomen and Gastrointestinal System Essay.
Past medical history(PMH); hypertension, diabetes, gastrointestinal bleed 4years ago.
Medications; Lisinopril 10mg,amlodipine 5mg,metformin 1000mg,lantus subcutaneously.
Allergies: No known drug allergies
Family History(FH): No colon cancer, father: Hypertension, diabetes T2, Mother: hypertension, hypercholesteromia.
Social: Denies tobacco used, Drink alcohol occasionally, married with 3 children; 2boys and 1girl
Objective data: Vital signs: Temp 99.8, pulse 92, respiratory rate 16, Blood pressure 160/86, HT 55’10” WT 248LBS
Heart : respiratory rate regular, no murmurs
Lungs: symmetrical chest wall
Skin: Intact without lesions, no urticarial
Abdomen: soft hyperactive bowel sounds, positive pain in left lower quadrant pain.Abdomen and Gastrointestinal System Essay.
Assessment: Left lower quadrant pain and gastroenteritis
Question#1: Analyze the subjective portion above and list additional information that should be included in the documentation.
Q2) Analyze the objective data above and list information that should be included in the documentation,
Q3) Is the assessment supported by the subjective and objective information” Why? Or why not”
Q4) What diagnostic tests would be appropriate for this case and how would the results be used to make a diagnosis.
Q5) Would you reject/or accept the current diagnosis? Why? Why not?Identify 3 possible differential diagnoses for the patient. And explain your reasoning using at least 3 current eveidence-based literature.Abdomen and Gastrointestinal System Essay.
Please answer in 1-2pages . Need the paper ready by Saturday october10th
Abdomen and Gastrointestinal System
After reviewing the subjective segment of the SOAP note, it is vital to include a Review of Systems (ROS). The ROS is a set of unique body frameworks intended to record all present or past symptoms of a patient (Philips et al., 2017). For this context, ROS should include the following:
It is also necessary to have a genital or rectal examination in the objective portion. Diagnosis should include a pregnancy test as it is conducted in all females of reproductive age. CBC screening should have also been conducted to test for WBC counts. Additionally, BMP tests for electrolyte levels attributable to vomiting or diarrhea, and stool culture should have been conducted.Abdomen and Gastrointestinal System Essay.
The assessment is not validated by the objective information since what is important to the history, HPI, and CC is included in the objective information. The details in the objective portion are not adequate to render a correct diagnosis. Diagnostic evaluations have not been performed, and that renders the objective portion of the SOAP note deficient. There ought to be a stool culture, BMP, CBC, and a pregnancy test. Abdomen and Gastrointestinal System Essay.
The healthcare provider can rule out the pregnancy if the test becomes negative; however, the CBC and stool culture would tell whether the manifestations are attributable to a bacterial or viral infection. This would customize the treatment plan that the provider would provide. Antibiotics treat bacteria-induced gastroenteritis (Kim et al., 2019). I would not embrace the present diagnosis as there were no essential diagnostics performed. The present diagnosis appears appropriate, but we cannot acknowledge that before a CBC, pregnancy test, and stool culture are performed. The potential differential diagnoses include: Abdomen and Gastrointestinal System Essay.