Soap Assessing the Abdomen Assignment
Soap Assessing the Abdomen Assignment
Assessing the Abdomen
Subjective Data
Patient Particulars
Initials: J.R
Gender: male
Age: 47 years
Race: white
Chief Complaint: abdominal pain and diarrhea.
History Of The Presenting Illness
J.R is a47 years old white male who complained of diffuse abdominal pain, which was of acute onset, increasing in frequency and intensity, and radiating to the lower abdominal region.
The pain was aggravated by meals and relieved by defecation. The abdominal pain is associated with diarrhea that is watery, foul-smelling, and mucoid.
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The patient reports other symptoms such as abdominal distension, loss of appetite, chills, and rigors, heartburn, nausea, and vomiting. The patient denies rectal bleeding, weight loss, and constipation.
Past Medical History: The patient is known to have had hypertension, diabetes mellitus, and upper GI bleeding for four years.
She has had two episodes of blood transfusion each 1liter. She has been admitted to the hospital twice due to diabetes mellitus and upper GI bleeding. Soap Assessing the Abdomen Assignment
Current Medication: the patient is on Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, and Lantus 10 units qhs.
Surgical History: none
Immunization: up to date. The last pneumococcal vaccine was six months ago
Allergies: no known food or drug allergy.
Social History: the patient is married and her three children (one 1girl and 2boys). He works as a call center manager. He denies tobacco use and occasionally takes ETOH.
Family History: the patient is the firstborn in his family. His siblings are alive and healthy. His father has type 2 DM and hypertension. His mother has hypertension, hyperlipidemia, and GERD. There is no known history of colon cancer in his family.
Review Of Systems
General: the patient denies generalized body weakness, weight loss, and night sweats.
HEENT: the patient does not complain of a headache, blurring of vision, earache, throat pain, and hoarseness of the voice.
Respiratory system: the patient denies a cough, chest pain, running nose, wheezing, sputum, and breathlessness
Cardiovascular system: the patient denies of palpitations, syncope, orthopnea, paroxysmal nocturnal dyspnea.
Genitourinary system: the patient denies polyuria, dysuria, hematuria, and urine incontinence.
Musculoskeletal system: the patient denies joint pain, stiffness, and muscle pull. Soap Assessing the Abdomen Assignment
Neurological system: the patient is oriented with good memory and actively listening.
Skin: the skin is smooth with no history of itchiness and breakouts.
Objective Data
General: The patient appears to be in pain holding his abdomen. However, he is not pale or dehydrated. He does not have jaundice, cyanosis, edema, and lymphadenopathy.
Vitals: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Abdominal examination: the abdomen is soft with a normal contour, no distension or flank fullness, no therapeutic marks, and no organ enlargement.
The bowel sounds are present and hyperactive. There is tenderness on the left lower quadrant. Murphy’s sign is negative. There is a tympanic percussion note and there are no fluid thrills or shifting dullness.
Cardiovascular: the heart is palpable at the 5th intercostal space midclavicular line. The heart sounds S1and S2 are present. There are no murmurs, parasternal heaves, and thrills.
The peripheral pulse is weak and collapsing with a regular rhythm and rate.
Respiratory system: the chest wall is symmetrical during expansion. There are no scars and organ enlargement. There is a resonant percussion note.
The lung fields are clear with vesicular breath sounds. No crackles, wheeze, or transmitted sounds were heard on auscultation.
Neurological: the patient is oriented to time place and person. The cranial nerves are intact. The speech is of normal tone, volume, and speed. The thought process is congruent, future-oriented, and positive. No hallucinations and deliriums were noted.
Musculoskeletal: the patient assumes a normal walking posture and gait.
Diagnostic Tests
I would do a complete blood count to screen for infections, inflammation, and anemia. A metabolic panel is appropriate to evaluate metabolic disorders and electrolyte imbalance.
Stool examination tests checks for parasites, ova, leukocytes, h.pylori antigen, and enteric pathogens. An abdominal ultrasound, OGD, and colonoscopy imaging are appropriate in checking the abdominal organs anomaly.
Assessment
The assessment is supported by the subjective data and the objective data. The patient’s complaints correspond with the findings in the objective data.
The abdominal findings of hyperactive bowel left lower quadrant tenderness, and fever corresponds with the abdominal pain and diarrhea to form a diagnosis. Soap Assessing the Abdomen Assignment
The actual diagnosis for the patient is irritable bowel syndrome because of the presenting symptoms of progressive diffuse abdominal pain, diarrhea, fever, hyperactive bowel sounds, and left lower quadrant tenderness.
He also has a previous history of upper GI bleeding. dyspepsia, and reflux. Gastroenteritis is not the diagnosis for the patient because it does not present with progressive abdominal pain and abdominal tenderness.
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Differential diagnosis
Irritable bowel syndrome
Acute appendicitis
Gastroenteritis
Irritable bowel syndrome is a gastrointestinal disorder characterized by abdominal pain and altered bowel habits without organic pathology (Ford, et al, 2018).
Common presenting signs and symptoms are diffuse abdominal pain that may radiate to the left lower quadrant, postprandial urgency, and diarrhea. The diarrhea is small volumes of loose stools.
The patient also presents with heartburn,
Acute appendicitis is the inflammation of the inner lining of the vermiform appendix. The presenting signs and symptoms are abdominal pain radiating the umbilical region and the left lower quadrant.
Other symptoms are nausea, vomiting, anorexia, and diarrhea (Stringer, M. D. 2017). There is guarding of the abdomen and rebound tenderness.
Gastroenteritis is the inflammation of the intestines due to the manifestation of bacterium and viruses (Sunkara, et al, 2019). Presenting symptoms are diarrhea, abdominal pain, nausea, vomiting, and abdominal tenderness.
References
Ford, A. C., Moayyedi, P., Chey, W. D., Harris, L. A., Lacy, B. E., Saito, Y. A., & Quigley, E. M. (2018). American College of Gastroenterology monograph on management of irritable bowel syndrome. Official journal of the American College of Gastroenterology| ACG, 113, 1-18.
Stringer, M. D. (2017). Acute appendicitis. Journal of paediatrics and child health, 53(11), 1071-1076.
Sunkara, T., Rawla, P., Yarlagadda, K. S., & Gaduputi, V. (2019). Eosinophilic gastroenteritis: diagnosis and clinical perspectives. Clinical and experimental gastroenterology, 12, 239. Soap Assessing the Abdomen Assignment
