Medical examination of the abdomen

Medical examination of the abdomen

Case Study

ABDOMINAL ASSESSMENT

Subjective:

  • CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
  • HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
  • PMH: HTN, Diabetes, hx of GI bleed 4 years ago
  • Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
  • Allergies: NKDA
  • FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
  • Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

  • VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
  • Heart: RRR, no murmurs
  • Lungs: CTA, chest wall symmetrical
  • Skin: Intact without lesions, no urticaria
  • Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
  • Diagnostics: None

Assessment:

  • Left lower quadrant pain
  • Gastroenteritis

To Prepare

Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

  • With regard to the Episodic note case study provided:
    • Review this week’s Learning Resources, and consider the insights they provide about the case study.
    • Consider what history would be necessary to collect from the patient in the case study.
    • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
    • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

  1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
  3. Is the assessment supported by the subjective and objective information? Why or why not?
  4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
  5. 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.

 

I have attached the template of focused /episodic note to help you find some of the information that are missing and that can be included in the documentation

For example

The character of the pain is not mentioned, the aggravating factors as well

The frequency of some medications is not listed, the indication as well

No foods or environmental allergies mentioned

For review of system (ROS): Nothing listed for subjective data and more details needed for objective data especially the Abdomen

Ect…

Please compare the episodic note case study to the template to assist you in findings additional information that can be included

Use Heading for each major part of the assignment

Examples

  1. Analysis of subjective portion of the note and subjective information that should be included
  2. Analysis of objective portion of the note and objective information that should be included
  3. Analysis of the assessment (Whether supported by the subjective and objective information? Why or why not?)
  4. Appropriate diagnostic tests and how the results would be used to make a diagnosis
  5. Is the Current Diagnosis Acceptable?
  6. Conditions That Could Be Considered a Different Diagnosis (3 of them supported by references)

(You can come up with your own heading as well but please cover all contents of the

assignment)

Thank you!

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Solution to Medical examination of the abdomen

Analysis of the Subjective Portion

What was the patient’s last 24-hour meal recall before diarrhea started? Uptake of contaminated food allergies, intolerance, or raw food is a leading cause of diarrhea. This will help us identify whether food poisoning is the cause. Inquiring about the travel history will help us rule out travelers’ diarrhea caused by mostly enterotoxigenic E coli, salmonella, shigella, rotavirus, and campylobacter (Leung et al., 2019). A reported outbreak of diseases such as cholera is critical in identifying the cause of diarrhea. More often than not, bloody diarrhea indicates GI bleeding due to an infection or injury to the intestine lining. The consistency of the stool, whether watery, mushy, or shapeless, helps identify the probable etiology. Rice water diarrhea is a common finding in cholera patients.

The patient should further describe the abdominal pain, explaining the character, aggravating, whether radiating or non-radiating, relieving, and timing of the pain. This will help to identify the affected part of the GI. For instance, if the abdominal pain is experienced before or after food intake, it most likely points to ulcer disease. The associated symptoms such as heartburn, vomiting, and bloating are also essential to consider.

Given the patient’s prior history of GI bleeding, it is vital to identify upper or lower bleeding. Review of systems is a guide to help in identifying underlying diseases. Recent use of antibiotics is vital. Antibiotics such as ampicillin, ciprofloxacin, clarithromycin, and cefpodoxime are likely to cause diarrhea (Blaabjerg et al., 2017). The frequency of the patient’s diabetic and hypertensive medication is essential to know whether or not the condition is well controlled. Lastly, inquire whether there is any other family member or friend with the same complaints to help rule out ingestion of contaminated food.

Analysis of the Objective Portion

Note the patient’s general status; pale, dehydrated, or sick looking. This will help assess the disease process and will guide in management. The findings on random blood sugar levels to determine the blood sugar control. On abdominal examination, explain whether there was any noticeable swelling, organomegaly on palpation, guarding or rebound tenderness, and percussion findings. This will help in narrowing down the overall diagnosis.

Analysis of the Assessment

Yes, the subjective information supports the diagnosis of gastroenteritis since it primarily presents with diarrhea accompanied by abdominal pain and nausea. The objective portion reveals a positive examination of left lower quadrant pain, which prompts further investigation; however, it is not a diagnosis.

Appropriate Diagnostic Tests

  • Complete blood count: check the white blood cell differentials to determine the probable cause of diarrhea. Check the hemoglobin level to rule out anemia.
  • Stool analysis: look for blood in stool, color, mucus consistency, and odor.
  • Stool for ova and cyst: rule out parasitic infections causing diarrhea.
  • Abdominal ultrasound: given the positive finding of LLQ pain, assess the organs and structures within the abdomen.
  • Kidney function test: increased fluid increases electrolyte imbalance, leading to acute kidney injury.
  • ESR: to detect inflammation as a result of infection or autoimmune disease.
  • C-reactive protein: detect inflammation caused by an infection, chronic disease, or injury. In our case, it will help rule out inflammatory bowel disease-inducing diarrhea episodes.
  • Colonoscopy: examine the large bowel.

Is the Current Diagnosis Acceptable?

Yes, gastroenteritis is acceptable; however, further investigations above are paramount to rule it in or out. However, the left lower quadrant is not an acceptable diagnosis since it is an examination finding, and therefore further studies are needed to identify the cause.

Differential Diagnoses

  • Gastroenteritis (A09): a pathologic state of the GIT often caused by infectious agents, which include; viruses, bacteria, and parasites. The primary presentation is diarrhea, but it may also be associated with abdominal pain, nausea, and vomiting (Burair Al Jassas et al., 2018).
  • Irritable bowel syndrome (K58.0): this is a functional gastrointestinal disorder that comprises symptoms that occur together. They include; changes in bowel motion which can be constipation, diarrhea, or both and repeated episodes of abdominal pain. The abdominal pain is mostly diffuse and non-radiating, specifically in the LLQ, and tends to be aggravated after meals (Lehrer, 2021). Other symptoms associated with the disease include bloating, food intolerance, nausea, vomiting, heartburn, and mucoid stool. The specific causative agents are however not well defined.
  • Inflammatory bowel disease (K51.90): a group of intestinal disorders that lead to prolonged gut inflammation. They are divided into two types;
  • Ulcerative Colitis (K51): This inflammatory bowel disease leads to inflammation and bleeding ulcers within the inner lining of the large bowel. The presenting complain includes; diarrhea, abdominal pain, weight loss, nausea, and blood in the stool (Basson, 2021). Research has shown that ulcerative colitis is an autoimmune disease whereby the immune system attacks the normal gut flora leading to inflammation.
  • Crohn’s disease (K50.90): This chronic inflammatory bowel disease affects the GUT lining. It commonly occurs in the small and large intestines; however, it can affect any part of the digestive tract from the mouth to the anus (Rendi, 2021). The symptoms often develop with time, whereas other symptoms worsen with time. They comprise; diarrhea, abdominal pain, loss of appetite, weight loss, and bloody stool. The symptoms often vary and can change over time. The specific etiology of Crohn’s is not determined; however, research has linked it to the interplay of genetics, immunity, and the environment.
  • Diverticulitis (K57.92): occurs when the diverticular (small pouches that form the inner lining of the intestines) becomes infected or inflamed. Symptoms can appear suddenly or develop gradually over several days. They include; diarrhea or constipation, lower left quadrant abdominal pain, blood in stool, nausea, and vomiting (Elie, 2019). The causes are not yet determined; however, the risk factors include; genetics, dietary habits, obesity, reduced immune function, smoking, and others.
  • Amoebiasis (A06.9): a parasitic infection brought about by Entamoeba histolytica, transmitted through ingesting contaminated food or water and sometimes through direct contact with contaminated fecal matter (Vinod, 2021). The cardinal symptoms are; diarrhea and abdominal pain. Other symptoms include; blood in stool, loss of appetite, nausea, and flatulence.

References

Basson, M. D. (2021, April 29). Ulcerative Colitis: Practice Essentials, Background, Anatomy. Medscape.com; Medscape. https://emedicine.medscape.com/article/183084-overview

‌Blaabjerg, S., Artzi, D., & Aabenhus, R. (2017). Probiotics for the Prevention of Antibiotic-Associated Diarrhea in Outpatients—A Systematic Review and Meta-Analysis. Antibiotics6(4), 21. https://doi.org/10.3390/antibiotics6040021

‌ Burair Al Jassas, Khayat, M., Alzahrani, H., & Mamdouh Mahbub. (2018, October 17). Gastroenteritis in adults. ResearchGate; Media Academy. https://www.researchgate.net/publication/328344392_Gastroenteritis_in_adults

‌ Elie. (2019, November 10). Diverticulitis: Practice Essentials, Background, Pathophysiology. Medscape.com; Medscape. https://emedicine.medscape.com/article/173388-overview

Lehrer, J. K. (2021, April 3). Irritable Bowel Syndrome (IBS): Practice Essentials, Background, Pathophysiology. Medscape.com; Medscape. https://emedicine.medscape.com/article/180389-overview

Leung, A. K. C., Leung, A. A. M., Wong, A. H. C., & Hon, K. L. (2019). Travelers’ Diarrhea: A Clinical Review. Recent Patents on Inflammation & Allergy Drug Discovery13(1), 38–48. https://doi.org/10.2174/1872213×13666190514105054

‌Red, M. (2021, April 3). Crohn Disease Pathology: Overview, Epidemiology, Etiology. Medscape.com; Medscape. https://emedicine.medscape.com/article/1986158-overview

Vinod. (2021, July 19). Amebiasis: Background, Pathophysiology, Etiology. Medscape.com; Medscape. https://emedicine.medscape.com/article/212029-overview

 

 

 

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