Abdominal Assessment Case Study SOAP Note

Abdominal assessment case study | Nursing homework help

Analysis of Subjective Portion:

The subjective portion of the note indicates that the patient has generalized abdominal pain that started three days ago. He rates the pain as 5/10 today, but it has been as high as 9/10 when it first began. The patient reports having diarrhea and feeling nauseous after eating. Additional information that could be included in the documentation includes the frequency, duration, and consistency of the diarrhea, as well as any recent changes in diet or stress level that could be contributing to the symptoms.

Analysis of Objective Portion:

The objective portion of the note indicates that the patient’s vital signs are within normal limits, except for an elevated blood pressure of 160/86. The abdominal assessment shows hyperactive bowel sounds and positive pain in the left lower quadrant. Additional information that could be included in the documentation includes the character and severity of the pain, whether it radiates to other areas, and whether there is any tenderness or swelling in the abdomen.

Assessment:

The assessment of left lower quadrant pain and gastroenteritis is supported by the subjective and objective information provided in the note. The patient reports abdominal pain and diarrhea, and the abdominal assessment shows positive pain in the left lower quadrant and hyperactive bowel sounds.

Diagnostic Tests:

Appropriate diagnostic tests for this case may include stool culture and sensitivity testing, complete blood count (CBC), electrolyte panel, and imaging studies such as a computed tomography (CT) scan or abdominal ultrasound. The results of these tests could be used to make a diagnosis by ruling out other conditions and identifying any underlying infections, inflammation, or structural abnormalities.

Current Diagnosis:

Based on the information provided in the note, the current diagnosis of gastroenteritis is plausible, but other conditions should be considered as differential diagnoses before confirming the diagnosis. More information is needed to rule out other possible causes of the patient’s symptoms.

Differential Diagnoses:

Three possible differential diagnoses for this patient include inflammatory bowel disease (IBD), diverticulitis, and appendicitis. IBD is characterized by chronic inflammation of the digestive tract and can cause abdominal pain, diarrhea, and weight loss. Diverticulitis is an infection or inflammation of small pouches that form in the colon and can cause left lower quadrant pain, fever, and changes in bowel movements. Appendicitis is an inflammation of the appendix that can cause right lower quadrant pain, fever, and nausea.

References:

1. Danese, S., & Fiocchi, C. (2011). Ulcerative colitis. The New England Journal of Medicine, 365(18), 1713-1725.
2. Peery, A. F., Sandler, R. S., Ahnen, D. J., Galanko, J. A., Holm, A. N., Shaukat, A., … & Burke, C. A. (2015). Constipation and a low-fiber diet are not associated with diverticulitis. Clinical Gastroenterology and Hepatology, 13(2), 320-326.
3. Di Saverio, S., Birindelli, A., Kelly, M. D., Catena, F., Weber, D. G., Sartelli, M., … & Davies, R. J. (2017). WSES Jerusalem guidelines for diagnosis and treatment of acute appendicitis. World Journal of Emergency Surgery, 12(1), 1-24.