Assessment of the Abdomen and Gastrointestinal System 

Further Information on Documentation

Subjective Portion

The patient’s recent dietary habits, specifically any recent changes in diet or new foods consumed, as well as any recent travel history or exposure to sick individuals should be documented. The patient’s usual bowel habits, frequency, consistency and color of stools, as well as any changes in these should also be recorded. You should note any other symptoms like fever, vomiting, weight loss, or nausea.

Obligatory Portion

The patient’s abdominal examination should be further detailed by recording the location, intensity, and character of the pain, as well as any rebound tenderness, guarding, or masses felt on palpation. Documentation should be made of the presence of hepatosplenomegaly or jaundice. To determine if there is blood in the stool, a rectal exam should be performed.

Assessment:

As the patient reported generalized stomach pains, diarrhea and nausea, the objective and subjective information support the diagnosis of gastroenteritis. Hyperactive bowel sounds were also found in the physical exam. This is consistent with gastroenteritis.

Diagnoses and Diagnostics:

For gastroenteritis caused by bacterial, viral, and parasitic infections, stool culture may be ordered. To check for signs and electrolyte imbalances, blood tests may be ordered. A CT or abdominal scan can also be ordered to determine if there are any structural abnormalities within the gastrointestinal tract.

The current diagnosis of gastroenteritis is acceptable given the patient’s symptoms and physical exam findings.

Differential Diagnosis

  1. IBD: IBD can present with chronic diarrhea and abdominal pain. It also causes weight loss. It is often associated with inflammation of the digestive tract. This condition can be diagnosed by colonoscopy or biopsies.
  2. Diverticulitis (or bowel inflammation) is when the pouches of the colon become infected and become inflamed. It can lead to symptoms like nausea, vomiting and abdominal pain. This condition is frequently diagnosed with CT scan.
  3. Irritable Bowel Syndrome: IBS is characterized by symptoms like abdominal pain, bloating and altered bowel habits. This condition can be diagnosed by looking at symptoms, and ruling out any other possible causes.

References:

  1. Crohn’s and Colitis Foundation. (2022). Inflammatory bowel disease. Retrieved from https://www.crohnscolitisfoundation.org/what-is-ibd
  2. Mayo Clinic. (2021). Diverticulitis. Retrieved from https://www.mayoclinic.org/diseases-conditions/diverticulitis/symptoms-causes/syc-20371758
  3. American College of Gastroenterology. (2022). Irritable bowel syndrome. Retrieved from https://gi.org/topics/irritable-bowel-syndrome/
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