Assessment of a Patient s Abdominal Pain

Assessing the Abdomen

Abdominal pain has proven to be a major issue facing emergency room doctors since the diagnosis process is relatively complex. Meisel (2011) contends that doctors in emergency rooms do not fancy diagnosing and treating abdominal pain because it entails dealing with bodily fluids, complex internal examinations, and a wide range of diagnostic tests and therapies. This comes at a time when abdominal pain is one of the major reasons American patients visit the emergency room (ER). Caring for abdominal pain is characterized by a high chance of misdiagnosis unlike other health issues. ER doctors are faced with challenging and time-consuming processes when trying to determine the actual cause of abdominal pain. This is a case study of a woman who visited an emergency room for severe abdominal pain and was diagnosed with diverticulitis. The case study entails an analysis of SOAP (Subjective, Objective, Assessment, and Plan) factors in describing abnormal findings relating to the woman’s condition.

Case Analysis

Diagnosis of a patient’s abdominal pain or cramping is a complex process that requires consideration of various factors that could be contributing to the pain. In this case study, information regarding the patient’s abdominal pain has been provided using the SOAP framework. This framework is commonly used in clinical settings to help describe abnormal findings relating to a patient’s condition. For this case study, SOAP was utilized to help identify abnormal issues relating to the individual’s abdominal pain. The information provided through this technique can be utilized to help nurses prepare themselves to better diagnose conditions in the abdomen. This use of this technique in abdominal assessment also involved collecting information regarding the patient’s history as well as conducting physical examinations and diagnostic tests.

Subjective Portion of the Note

An important part in accurate diagnosis of a patient with severe abdominal pain is collecting his/her medical and social history. According to Macaluso & McNamara (2012), collection of the patient’s history should incorporate a complete description of his/her pain as well as medical, social, and surgical information. Based on the subjective portion of the note provided relating to this patient’s condition, the patient’s history, medical, and social information was collected. Additionally, the subjective portion of the note provides a description of the extent of abdominal pain. However, the description does not include information regarding the exact location of the abdominal pain, its associating symptoms, and aggravating factors. Therefore, additional information that should be included in the subjective portion of the note include the precise location of the pain, its associating symptoms, alleviating factors, and aggravating factors. Such information is usually critical when describing a history of the present illness (HPI) and helps in determining a proper diagnosis for the condition.

Objective Portion of the Note

The objective portion of the note provides information relating to the vital signs of the patient’s abdominal pain. Moreover, the clinician has also included information about the individual’s physical assessment results under the objective section. However, the subjective portion of the note lacks some important information that would help in proper diagnosis of the patient’s situation. Some additional information that should be included in the documentation under the objective section include physical assessment results relating to eyes, ears, nose, throat or mouth, lymph nodes, and extremities. This information is essential to help in understanding the associated symptoms of the abdominal pain as well as its alleviating or aggravating factors, which is vital during diagnosis.

Assessment

Based on information from the subjective and objective portions of the note, the clinician found the patient to suffer from either gastroenteritis or left lower quadrant pain. The assessment was seemingly supported by the subjective and objective information, which indicated signs of these conditions. For example, some of the signs of gastroenteritis include high temperature and crampy pains in the abdomen. The subjective and objective information demonstrated that the patient had high temperature and left lower quadrant pain, which led to the diagnosis of gastroenteritis. Additionally, the patient had other symptoms of this condition including diarrhea, nausea, and crampy pains in the abdomen. The diagnosis of left lower quadrant pain was supported by the subjective and objective information, particularly the physical assessment of the patient’s abdomen, which traced the pain to the left lower quadrant. In this regard, the assessment is supported by the listed subjective and objective information.

Consequently, I would accept the current diagnosis since its accurately based on the subjective and objective information. However, there are some diagnostic tests that would be appropriate for this case and help in making a diagnosis. One of the diagnostic tests is computed tomography, which is usually the preferred test in examining clinically suspected diverticulitis and pain in the left lower quadrant (Hammond, Nikolaidis & Miller, 2010). The results of computed tomography would be utilized to make a diagnosis through identifying causes of the pain in the left lower quadrant that mimic the diverticulitis. Moreover, information from this diagnostic test would help in diagnosis through providing information about the severity and extent of the disease. The second diagnostic test is magnetic resonance imaging, which is commonly used to evaluate left lower quadrant. It would help in making a diagnosis through resolution of soft tissues and lessening the patient’s exposure to ionizing radiation.

Differential Diagnosis

One of the probable conditions that this patient could be diagnosed with is diverticulitis, which is a condition that is characterized by left lower quadrant pain. Cartwright & Knudson (2008) contend that the location of the abdominal pain usually helps in precise diagnosis of a patient’s condition. In this regard, the patient could be suffering from diverticulitis since the subjective and objective information points to this condition. Cartwright & Knudson (2008) state that diverticulitis is one of the differential diagnoses of patients with left lower quadrant pain. Based on the listed medical, social and surgical information as well as the description of the abdominal pain, the patient could be suffering from diverticulitis.

The second differential diagnosis is colitis, which is a colonic differential diagnosis for patients with pain in the left lower quadrant. Abdominal pain, cramping, and diarrhea are some of the major symptoms of colitis (Hammond, Nikolaidis & Miller, 2010). While the patient may not exhibit severe symptoms of colitis, he could be suffering from this condition and requires further tests, particularly colonoscopy. The other differential diagnosis for the patient’s condition is acute left-sided colonic diverticulitis, which is a common condition that affects adults aged 40 years or more (Andeweg et al., 2013). This is based on the patient’s subjective and objective information, which indicates that the patient is suffering from gastrointestinal LLQ pain.

In conclusion, the diagnosis of severe abdominal pain is a relatively complex process that emergency room doctors face. The complex nature of the diagnosis process implies that emergency room doctors need to carry out different diagnostic tests to help identify the precise cause of the abdominal pain. As shown in this case study, the use of various diagnostic tests helps in development of differential diagnostics for abdominal pain as well as a suitable treatment approach for the condition.

References

Andeweg et al. (2013). Guidelines of Diagnostics and Treatment of Acute Left-Sided Colonic Diverticulitis. Digestive Surgery, 30(4-6). Retrieved from https://www.karger.com/Article/FullText/354035

Cartwright, S.L. & Knudson, M.P. (2008, April 1). Evaluation of Acute Abdominal Pain in Adults. American Family Physician, 77(7), 971-978.

Hammond, N.A., Nikolaidis, P. & Miller, F.H. (2010, October 1). Left Lower-Quadrant Pain: Guidelines from the American College of Radiology Appropriateness Criteria. American Family Physician, 82(7), 766-770.

Macaluso, C.R. & McNamara, R.M. (2012, September 26). Evaluation and Management of Acute Abdominal Pain in the Emergency Department. International Journal of General Medicine, 5, 789-797.

Meisel, Z.F. (2011, February 2). Why Belly Pain is Such a Headache for ER Doctors. Time. Retrieved April 7, 2018, from http://content.time.com/time/nation/article/0,8599,2045685,00.html