Abdomen Assessment

Assessing the Abdomen
Introduction
Understanding patient history is important when formulating a diagnosis of a patient. In the case of the patient JR, there is a lot of information that is not reported that could be very useful when determining the correct diagnosis for this patient. Some questions still need to be asked to find out what that history is and whether or not the new information would apply to JR’s case and help the nurse understand what is impacting his health more clearly. In this paper, a review of the SOAP will be conducted and a discussion of what physical exams are required in order to make it known what JR’s condition is or what is causing the symptoms that he is experiencing. The paper will also identify five conditions that may be considered a differential diagnosis for what is causing his pain.
Chief Complaint
JR has a chief complaint (CC) that his “stomach hurts” and he also says that “I have diarrhea and nothing seems to help.” This indicates that JR is not getting any relief from his symptoms regardless of what he does to alleviate the pain. The pain began a little less than half a week ago—approximately 3 days ago. JR states that he had not taken any medicine for his pain, but he is already on a different set of medicines for his high blood pressure and diabetes—so he is definitely not free of medication at this point. It is important to find out what medications he has been taking for a while and whether any of them or new to him because he might be having a reaction to these medicines. That is something that has to be determined.
While it is reported that he does not have any drug allergies, the personal history might be able to clear this up more conclusively and it could be found that he is indeed allergic to something he is taking now. There is also a family history of high blood pressure and some gas issues so there are is something to take into consideration as well. JR also notes that he drinks ethyl alcohol and that is something to keep in mind for a differential diagnosis because the alcohol could be aggravating something in his stomach such as an ulcer if it turns out that this is what is causing the pain. The soft sounds in his bowel could also be an indication of IBS.
Questions to Ask for Patient History
It is essential to pinpoint how long he has been on the medications he is on because some of them can have bad side effects for certain people. If he is new to these drugs then there needs to be some awareness of this so that a differential diagnosis regarding side effects to the drugs can be ruled out, especially if he has never had these problems before. Dujic (2016) states that these problems arise with drugs like Metformin, which is something JR is taking, in some people over time—so a sensitivity to this issue is required.
At the same time it has to be determined what the family history is because this is important too. For JR, it should be asked if his family has a history of GI problems and if there is anything in his past that might indicate that he himself has a history of GI problems so that the nurse can better understand the situation and have all the facts before making a diagnosis. It is crucial not to jump to conclusions before establishing what all the facts of the case are: a nurse is like an investigator in many ways and has to know what questions to ask—so in this case it is evident that JR had GI bleeding 4 years ago. The question to ask is: what caused this bleeding? Has he ever had it before? Has anyone in his family ever had it? Was it accompanied by a particularly stressful period in his life? Did the bleeding stop? Has he been under stress recently? How does he relax and what are his habits like? These questions can help to paint a picture of JR’s background and will indicate the possibility of JR suffering from an ulcer (Mustafa, 2015) because ulcers are commonly linked to stress and GI bleeding. If JR had an ulcer in the past, it is very likely that he might be suffering from another currently, especially if he is undergoing a lot of stress at the time as stress can aggravate it. That is why it is important to assess what is going on in his life and whether he is feeling stressful lately—so as to know if in fact his body is reacting to this stress with an ulcer.
There is also the matter of JR’s drinking. This could also play a part in the pain he is experiencing, especially if he is having an ulcer. There is a way to check for this of course by physical exam: looking for palpitation of abdomen, digital rectal exam, and testing for occult blood. However, JR should also undergo an allergy test to see if he is allergic to the drugs he is taking and these could be conducted through a skin test—though a simple questioning of his history with these drugs would likely be enough to settle the matter and this would only be to rule out a differential diagnosis. The most important first step would be to settle the matter of the GI bleeding and the possibility of an ulcer which could be tested by endoscopy or CT scan.
What are the Differential Diagnoses
The diagnosis by the nurse that JR is suffering from diverticulitis is too quickly made for me to feel comfortable with it. I want to know the background of his GI bleeding first and also if there is some history of his that needs to be known with the medications he is on. Some more information about his stress levels and drinking levels in the recent days would also be helpful as these could be factors to consider as well because they could be making his stomach ulcer worse if that is what we are dealing with here.
I would say that the most likely condition that he is suffering from is an ulcer, which is supported by the study by Mustafa (2015) and then I would even say that it is possible that he is suffering from irritable bowel syndrome (IBS) which would be supported by the study by Chanu and Raj (2018) as well as by Lenhart and Chey (2017). Finally, if neither of these two are found then we could maybe suggest that it is diverticulitis but we should also check to see if in fact he is not having an allergic reaction to his diabetes medication, which is very possible considering the study by Dujic (2016).
Of the three, IBS or an ulcer is the most likely to be the case—and of these two, I would say that the ulcer is what is causing the problems for JR, because he already has a history of GI bleeding and yet there is no information about what caused this GI bleeding, so that has to be figured out immediately. Three other things to consider are: the stress levels in his life and I would ask him to rank these on a scale of 1 to 10 with 1 being hardly any at all and 10 being unbearable. This could help to show if he is stressed and if that stress is likely to be impacted his condition. I would also need to know how much alcohol he has consumed in the past week because that could be hurting the situation even more as well. The family condition could be important but I would be more interested in knowing what his personal hobbies are, if he is getting any exercise, and how long he has been taking the medications he is currently on because they could be negatively impacting his health as well. There is no one stop way to check for all this so the questions all have to be asked one by one.


References
Chanu, O. R., & Raj, V. K. (2018). Acquisition and characterization of bowel sounds
using labview software. Biomedical Engineering: Applications, Basis and Communications, 30(02), 1850006.
Dujic, T., Causevic, A., Bego, T., Malenica, M., Velija?Asimi, Z., Pearson, E. R., &
Semiz, S. (2016). Organic cation transporter 1 variants and gastrointestinal side effects of metformin in patients with Type 2 diabetes. Diabetic Medicine, 33(4), 511-514.
Lenhart, A., & Chey, W. D. (2017). A systematic review of the effects of polyols on
gastrointestinal health and irritable bowel syndrome. Advances in Nutrition, 8(4), 587-596.
Mustafa, M., Menon, J., Muiandy, R. K., Fredie, R., Sein, M. M., & Fariz, A. (2015).
Risk factors, diagnosis, and Management of Peptic ulcer disease. J Dent Med Sci, 14, 40-6.