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...
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…
