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.  Lab Assignment Assessing the Abdomen Essay

In this Assessment 1 Assignment, you will analyze an Episodic Note case study that describes abnormal findings in patients seen in a clinical setting. This is in a scholarly paper format and not SOAP format this week. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions. Follow the rubric…..Be sure to use APA format…..and upload by Day 7.

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

ORDER NOW  HERE

Lab Assignment: Assessing the Abdomen

Missing subjective data       

The missing subjective information is on the history of present illness (HPI) and the review of systems or ROS.

Additional objective information

The additional objective information that should be added includes the general assessment on matters such as speech, grooming, and orientation in time, space, place, person, and event (Ball et al., 2019). Also to be added is information on the physical examination of the HEENT (head, eyes, ears, nose, and throat). For instance, it should be stated whether the head is normocephalic or not and if it is atraumatic or otherwise. The information on whether the pupils are both equal, round, and reacting to light and accommodation (PERRLA) is also required. Rhinorrhea, otorrhea, and throat erythema should all also be reported if present.

What the subjective and objective information supports in assessment

Information presented from the subjective and objective data appears to support the diagnosis of gastroenteritis or GE. Diarrhea, nausea, fever, pain, cramping, and left lower quadrant (LLQ) pain are all manifestations of gastroenteritis (Bányai et al., 2018; Hammer & McPhee, 2018; Huether & McCance, 2017). These presentations or symptoms will be the same regardless of whether the causative organism is a bacterium or a virus. The exact presentation of this 47 year-old male conforms to the above known manifestations of GE. He has diarrhea, nausea, fever, and LLQ pain. The exact ICD-10-CM diagnosis for him in this case would be gastroenteritis and colitis represented by the code A09. Lab Assignment Assessing the Abdomen Essay

Diagnostic Laboratory Tests

1. Stool sample for microscopy: Because of the diarrhea, it would be clinically sound to take a sample of the stool and examine it under a microscope. A culture and sensitivity test to determine the correct antibiotic for the bacterium responsible can also be done (Bashir & Gray, 2017). If nothing is seen under normal microscopy the cause would definitely be viral.  
2. Full blood count: A raised white blood count (leucocytosis) in a patient with fever indicates infection. Eosinophilia may also indicate the presence of a rare type of gastroenteritis referred to as eosinophilic gastroenteritis. The hemoglobin level will also show if they are anemic or not.

• Complete metabolic profile or CMP: The 47 year-old patient has some pre-existing chronic lifestyle conditions that warrant the performance of a CMP. He has a family history of hyperlipidemia but also has hypertension and diabetes that are already active. Knowing the cholesterol levels and other parameters such as the blood sugar levels or HbA1c will help in management planning.

1. Gastrointestinal endoscopy: Direct visualization of the pathologic processes and changes in the interior of the gut would be confirmatory of the changes caused by infectious GE.

The Diagnosis and differential diagnosis

1. Infectious GE and colitis

Infectious GE has a tendency of being comorbid with colitis (Hammer & McPhee, 2018; Huether 7 McCance, 2017).

2. Acute sigmoid diverticulitis

Left lower quadrant pain accompanied by cramps is characteristic of acute sigmoid diverticulitis too. This makes it the number one differential diagnosis (Hammer & McPhee, 2018; Huether 7 McCance, 2017).

3. Prostatitis

The patient is 47 years old and chances that he may be having prostatitis are also high. Acute inflammation of the prostate is common in men in this age bracket (Hammer & McPhee, 2018; Huether 7 McCance, 2017).

References

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bányai, K., Estes, M.K., Martella, V., & Parashar, U.D. (2018). Viral gastroenteritis. The Lancet, 392(10142), 175–186. https://doi.org/10.1016/s0140-6736(18)31128-0

Bashir, A., & Gray, J. (2017). Fight antibiotic resistance – it’s in your hands to improve antibiotic stewardship. Journal of Hospital Infection, 95(4), 361–362. https://doi.org/10.1016/j.jhin.2017.02.018

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6^th ed. Elsevier, Inc.

Lab Assignment Assessing the Abdomen Essay