Analyze the subjective portion of the note. List additional information that should be included in the documentation. Analyze the objective portion of the note. List additional information that should be included in the documentation. Is the assessment supported by the subjective and objective information? Why or why not? What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis? Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Wk 6 assignment 1 nurs 6512 | NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning | Walden University

Additional Information for Documentation:

Subjective:

• The frequency, amount, and color of diarrhea
• The type of food consumed before and after the onset of pain
• The presence of nausea and vomiting and the frequency
• The duration and intensity of pain
• The patient’s medical history related to gastrointestinal disorders
• Any medication use that may contribute to the gastrointestinal symptoms

Objective:

• A detailed description of abdominal pain
• A complete abdominal assessment, including all four quadrants
• A description of the stool and signs of blood in it
• Information on the patient’s hydration status
• Signs of dehydration such as dry mucous membranes, sunken eyes
• Results of any other diagnostic tests performed

The assessment is supported by the subjective and objective information since the patient is experiencing left lower quadrant pain and has hyperactive bowel sounds, indicating the possibility of gastrointestinal issues.

Diagnostic tests that may be appropriate for this case include:

• Stool sample for culture and sensitivity
• Blood test to check for inflammatory markers
• Abdominal ultrasound to check for any structural abnormalities
• Colonoscopy to examine the colon and rectum
• CT scan of the abdomen and pelvis

It is difficult to reject or accept the current diagnosis without further testing, as there are several conditions that could cause similar symptoms. The three possible conditions that may be considered in a differential diagnosis for this patient include:

• Inflammatory bowel disease (IBD)
• Diverticulitis
• Irritable bowel syndrome (IBS)

IBD is characterized by chronic inflammation of the gastrointestinal tract and can cause diarrhea, abdominal pain, and weight loss. Diverticulitis is the inflammation of the diverticula in the colon and can cause abdominal pain, diarrhea, and fever. IBS is a functional gastrointestinal disorder that can cause abdominal pain, bloating, and changes in bowel habits.

References:

• Ignjatovic, A., & Saunders, Y. (2019). Inflammatory bowel disease. Surgery (Oxford), 37(3), 145-151. doi: 10.1016/j.mpsur.2018.12.005
• Peery, A. F., Keku, T. O., & Martin, C. F. (2019). Diverticulitis: Epidemiology, natural history, and risk factors. Clinical Colon and Rectal Surgery, 32(3), 157-163. doi: 10.1055/s-0039-1688496
• Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: A clinical review. Journal of the American Medical Association, 313(9), 949-958. doi: 10.1001/jama.2015.0954