47-year-old male whose chief complaint is a hurting stomach diarrhea
Soap Analysis Paper
Subjective Data
The 47-year-old male whose chief complaint is a hurting stomach diarrhea, and nothing seems to help. The nurse should prompt the patient for more information in the HPI section describing the kind of pain he is experiencing, does it radiate, what makes it worse and it is it relieved by anything. Additionally, in the social history part, Dains et.al (2019) highlights that the use of acronym HEADSS standing for HOME and Environment, Education, Employment, Eating, Activities Drugs, Sexuality, and suicide/Depression can greatly help in assessing a patient. As such, while the patient reported that he occasionally drinks ETOH, he should state how and what he drinks, and the nurse should inquire whether he abuses any drug, whether he exercises (since the patient is obese based on CDC guideline at 248lbs) as well as his eating habits. This is because obesity can lead to certain GI problems, such as hiatal hernia and peptic ulcer. Moreover, the clinician should inquire about the patient’s diet, request for a 24-hour food recall, and whether he has any food intolerance. Order Now
The patient reported a history of GI bleeding 4 years ago hence it is crucial to inquire about the cause and the treatment prescribed in the past medical history. It should be noted that the patient’s father had a history of GERD among other diseases. For this reason, the nurse should inquire when he was diagnosed and at what age, and whether his current treatment is to manage the disease is a key factor. He further reported he has a history of diabetes which is a factor in escalating as well as developing gastrointestinal issues such as pancreatitis, ulcers and gastroparesis diseases (Ball et al., 2019). It is crucial to inquire whether the patient has noted a change in his bowel movements.
General assessment entails inquiring about any recent fever, chills to ensure that no active infection exists. Any symptoms of fatigue, weakness, hydration problems as well as patient’s grooming will help make a proper diagnosis. Essentially, in cardiovascular assessment, the nurse should inquire about pain to rule out cardiac involvement. Ask about burning chest pain, and palpitations, any edema in lower extremities, distress while lying down due to abdominal pain, and palpitations in addition to orthopnea.
The patient current medication includes Amlodipine 5mg, lisinopril 10mg, metformin 1000mg and Lantus 10 units qhs. A medication like metformin is associated with certain side effects, among them nausea, diarrhea and stomach upset. On the other hand, while assessing the abdomen, it is essential to inquire about appetite disturbances due to abdominal pain, indigestion, food intolerance, any history of dysphagia, positive for nausea, vomiting, hematemesis, bowel irregularity, etc. Further, it is important that the nurse inquire about when the patient had their last bowel movement. Any constipation, diarrhea, hemorrhoids, ulcer, gallstones, polyps, or tumors, or generalized abdominal pain should be recorded in the assessment (Colyar, 2015 47-year-old male whose chief complaint is a hurting stomach diarrhea).
Objective Data
In assessing abdominal pain, it is paramount to perform cardiovascular diagnostic tests since many patients are often diagnosed with heartburn when in fact they are in the middle of a heart attack. So many times, providers miss the diagnosis of cardiac disease when they present with other symptoms.
Abdominal assessment should follow the four cardinal rules that start with the visual inspection for abnormalities, color distribution, rash, sore, stretch marks, symmetry, unusual bulging, dept., or pulsation, then proceed to auscultation and then palpation. Palpation is always done last as it always interferes with the integrity of abdominal sound due to its potential of creating or stimulating a false bowel sound. Significantly, genitourinary assessment entailing any changes in urine patterns such as polyuria or nocturia as well as consistent or burning sensation when urinating should be noted. Furthermore, he should state whether he is experiencing genital pains such as testicular and suprapubic pain as well as the presence of hematuria. Besides, the nurse should inquire about the history of kidney stones or pain in the kidneys (Colyar, 2015).
Assessment
As such, both subjective and objective information support the assessment revealing left lower quadrant pain and gastroenteritis. The subjective information illustrates the possible existence of gastroenteritis, which often presents with general abdominal pain, nausea and diarrhea. However, the physical assessment discloses Post pain in the left quadrant.
Diagnostics tests
Different diagnostic tests should be performed to facilitate accurate diagnosis. A count of white blood cells (WBC) should be performed to examine the existence of infections. This implies a keen WBC examination can detect the existence of infections (LeBlond, & DeGowin, 2014). The tests include complete blood count (CBC) which assist in determining the probability of loss of blood. Internal bleeding especially in the gut is usually associated with low CBC. Since the patient experiences pain in the left lower quadrant, it is crucial to perform a CT scan to examine the cause of his pain (Colyar, 2015). Moreover, Obtaining an EKG along with a troponin are diagnostics that should be ordered on the patient to assist in ruling out cardiovascular issues. An abdomen CT scan will examine the bowel, the left kidney, abdomen, and the ureter. As well, a testicular ultrasound should be performed to rule out the existence of testicular problems that may result in the reported left lower quadrant abdominal pain. To examine the existence of gut infection, it is vital to perform a stool culture test. Additionally, a heme-occult examination can equally be conducted to examine the probability of blood in the stool (LeBlond, & DeGowin, 2014).
Differential Diagnoses
Gastroenteritis
It is a disease that affects anyone regardless of age. Considering the patient’s physical assessment and history, a positive diagnosis of gastroenteritis is ideal. The patient experiences crampy pain, has nausea, and reports vomiting and diarrhea (Dains et.al, 2019). In addition, he gets hyperactive bowel and positive generalized abdominal pain. Basically, this condition is self-limiting and requires supportive care for the symptoms of nausea, vomiting, diarrhea, and fever. The provider will generally hear hyperactive bowel sounds upon auscultation (Dains et.al, 2019).
GERD
GERD is also a more likely diagnosis and it classically includes both the symptoms of heartburn and regurgitation in the disorder; therefore, the patient will complain of painful retrosternal burning, typically after a meal and increased pain often at night and is likely to bring up acidic liquids or belches (LeBlond, & DeGowin, 2014). Due to the reflux of stomach acid, patients often experience voice hoarseness and redness of the pharynx, as this patient exam showed. Furthermore, there is a strong link between GERD and an increased BMI (Ball et al., 2019). The patient is obese based on CDC guideline and occasional alcohol use. The patient is also on multiple medications, some of which have been shown to increase gastrointestinal (GI) disturbances such as GERD, dyspepsia, gastric ulcers, and upper GI bleeds (LeBlond, & DeGowin, 2014).
Gastritis
Gastritis is defined as a persistent burning pain in the epigastric area and usually associated with vomiting, nausea, diarrhea, and fever. Often, alcohol, anti-inflammatory drugs, non- steroidal, and salicylates tend to escalate the pain (Ball et al., 2019). Patient has a history of ETOH use but is currently not taking salicylate medication. Abdominal assessment reveals generalized pain to left lower quadrant with tenderness to palpation, rather than epigastric type pain, indicating a likely gastritis.
Peptic ulcer
Diagnosis of peptic ulcer entail checking bloating, tenderness and pain. CT scan helps in diagnosing whether the condition has perforated a hole on the wall of the small intestine or stomach wall. Perforation causes radiating pain and the patient usually has h/o gnawing pain that worsens on an empty stomach. However, Ball et al., (2019) notes that the pain may still be present even when the patient has a full stomach.
47-year-old male whose chief complaint is a hurting stomach diarrhea References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. https://www.elsevier.com/books/seidels-guide-to-physical-examination/ball/978-0-323-48195-3
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.