Assessing the Abdomen

Assessing the Abdomen A comprehensive assessment and physical examination is essential in making the correct diagnosis. In addition to laboratory and imaging findings, objective and subjective data plays a great role in diagnosing a gastrointestinal condition. In this paper, a SOAP case study of JR will be analyzed to provide the required additional informal as well as the differential diagnosis of the case.

Additional Information Required on the Subjective Data The subjective data provided has the required information that could be inquired from the patient. Adequate family and health history were obtained. To obtain a comprehensive history of present illness, the OLDCARTS mnemonic can be used to represent Onset of symptom, Location of symptom, Duration of symptom, Character of symptom, Aggravating/Alleviating Factors, Radiation of symptom (if pain), Timing of symptom, Treatment received and Severity of symptom. Additionally, the review of systems should have been added to the subjective data.

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Additional Information Required on the Objective Data The objective data was well documented. However, the information should have been more detailed and included more body systems. Since the chief complaint was on the abdomen, the abdominal assessment should have included distension, the position of bowel sounds, pain, and tenderness. It should also have checked for hepatosplenomegaly.

Whether Objective and Subjective Data support the Assessment Yes. Both objective and subjective data have supported the assessment. This is because objective and subjective information have been obtained from the patient and can be used in diagnosing the patient’s condition.

The Diagnostic Tests Required and their Relevance in Diagnosing the Condition Stool microscopy – This test is required to check for intestinal parasites which are the most common cause of diarrhea and abdominal pains.

Full blood count – this test is necessary to check for infections through blood parameters.

Bacterial and viral infections which affect the gastrointestinal system affects the white blood cell parameters.

Stool antigen tests – Antigen tests are done to check for specific antibodies in the stool.

In this case, several specific antigen tests could be done based on the patient’s epidemiological risk and presenting symptoms. This includes salmonella antigen, cholera antigen, rotavirus, and adenovirus among others (Humphries & Linscott, 2015).

Differential Diagnosis Gastroenteritis is the most probable condition in this scenario, and I support its diagnosis.

This is because it causes acute diarrhea and stomach pain among other symptoms (Leshem &

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Lopman, 2018). Bacterial and viral infections are responsible for gastroenteritis, and the two can be distinguished through stool culture and sensitivity tests (Humphries & Linscott, 2015).

Parasitic infection is another common cause of diarrhea especially among patients with recent travel history to endemic areas (Schiller, Pardi, & Sellin, 2017). Stool microscopy is often used to diagnose and differentiate parasitic infections by looking at their eggs, ova or cysts.

Food poisoning is another probable cause of the patients’ symptoms. It is caused by ingesting contaminated food or drink (Ball, Dains, Flynn, Solomon, & Stewart, 2015). The last differential diagnosis is diverticulitis, which is the inflammation of the diverticula found on the walls of the small intestine.

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References Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Humphries, R. M., & Linscott, A. J. (2015). Laboratory diagnosis of bacterial gastroenteritis.

Clinical Microbiology Reviews, 28(1), 3-31.

Leshem, E., & Lopman, B. A. (2018). Viral gastroenteritis. In Principles and practice of pediatric infectious diseases (5th ed.) (pp. 383-387). Amsterdam, Netherlands: Elsevier.

Schiller, L. R., Pardi, D. S., & Sellin, J. H. (2017). Chronic diarrhea: diagnosis and management.

Clinical Gastroenterology and Hepatology, 15(2), 182-193.