Lab assignment: assessing the abdomen | NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning | Walden University
- In the subjective portion of the note, additional information that should be included in the documentation are:
- Detailed description of the abdominal pain (location, type, intensity, duration, frequency, aggravating and relieving factors)
- Presence of other gastrointestinal symptoms (vomiting, bloating, constipation, blood in stool)
- Recent changes in diet or lifestyle
- Any recent travel or exposure to infectious diseases
- Family history of gastrointestinal disorders
- In the objective portion of the note, additional information that should be included in the documentation are:
- Abdominal examination findings in other quadrants
- Rectal examination findings (if done)
- Results of any other diagnostic tests performed (if any)
- The assessment of gastroenteritis is supported by the subjective and objective information, as the patient presents with abdominal pain and hyperactive bowel sounds in the LLQ, which are consistent with the diagnosis. However, further investigations may be necessary to rule out other conditions that can present with similar symptoms.
- Diagnostic tests that may be appropriate for this case include:
- Stool culture and sensitivity to identify the causative organism in case of infectious gastroenteritis
- Complete blood count and electrolyte panel to assess for dehydration and electrolyte imbalances
- Abdominal ultrasound or CT scan to evaluate for any structural abnormalities or inflammation in the gastrointestinal tract
The results of these tests can help in making a diagnosis and determining appropriate treatment options.
- Based on the limited information provided in the case study, the current diagnosis of gastroenteritis may be appropriate. However, other conditions that may present with similar symptoms and should be considered in the differential diagnosis include:
- Inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis)
- Irritable bowel syndrome
These conditions can be differentiated through additional history taking, physical examination, and diagnostic tests. For instance, inflammatory bowel disease may present with persistent diarrhea, rectal bleeding, and weight loss, while diverticulitis may present with fever, chills, and localized abdominal tenderness.
- Crohn’s & Colitis Foundation. (2022). Symptoms of Crohn’s Disease. https://www.crohnscolitisfoundation.org/what-is-crohns-disease/symptoms
- American College of Gastroenterology. (2021). Irritable Bowel Syndrome. https://gi.org/topics/irritable-bowel-syndrome/
- American Society of Colon and Rectal Surgeons. (2019). Diverticulitis. https://www.fascrs.org/patients/disease-condition/diverticulitis-disease-0