1. Patient Assessment: Gastrointestinal System.
Patient Assessment: Gastrointestinal System. Review the Episodic note case study your
instructor provides you for this week’s Assignment. Please see the “Course Announcements”
section of the classroom for your Episodic note case study.• With regard to the Episodic
note case study provided: Patient Assessment: Gastrointestinal System.o Review this week’s
Learning Resources, and consider the insights they provide about the case study.o Consider
what history would be necessary to collect from the patient in the case study.o Consider
what physical exams and diagnostic tests would be appropriate to gather more information
about the patient’s condition. How would the results be used to make a diagnosis?o Identify
at least five possible conditions that may be considered in a differential diagnosis for the
patient.ORDER NOW. The Assignment1. Analyze the subjective portion of the
note. List additional information that should be included in the documentation. Patient
Assessment: Gastrointestinal System.2. Analyze the objective portion of the note. List
additional information that should be included in the documentation.3. Is the assessment
supported by the subjective and objective information? Why or why not?4. What diagnostic
tests would be appropriate for this case, and how would the results be used to make a
diagnosis?5. Would you reject/accept the current diagnosis? Why or why not? Identify three
possible conditions that may be considered as a differential diagnosis for this patient.
Explain your reasoning using at least three different references from current evidence-
based literature. Patient Assessment: Gastrointestinal System.SEE BELOWABDOMINAL
ASSESSMENTSubjective:• CC: “My stomach hurts, I have diarrhea and nothing seems to
help.”• HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3
days ago. He has not taken any medications because he did not know what to take. He states
the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been
able to eat, with some nausea afterwards. Patient Assessment: Gastrointestinal System.•
PMH: HTN, Diabetes, hx of GI bleed 4 years ago• Medications: Lisinopril 10mg, Amlodipine 5
mg, Metformin 1000mg, Lantus 10 units qhs• Allergies: NKDA• FH: No hx of colon cancer,
Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD• Social: Denies tobacco use;
occasional etoh, married, 3 children (1 girl, 2 boys)Objective:• VS: Temp 99.8; BP 160/86;
RR 16; P 92; HT 5’10”; WT 248lbs• Heart: RRR, no murmurs• Lungs: CTA, chest wall
symmetrical• Skin: Intact without lesions, no urticaria• Abd: soft, hyperactive bowel
sounds, pos pain in the LLQ• Diagnostics: NoneAssessment:• Left lower quadrant pain•
GastroenteritisPLAN:1. Analyze the subjective portion of the note. List additional
information that should be included in the documentation.Consider including a subject
2. heading reflective of this content.2. Analyze the objective portion of the note. List additional
information that should be included in the documentation.Consider including a subject
heading reflective of this content. Patient Assessment: Gastrointestinal System.3. Is the
assessment supported by the subjective and objective information? Why or why not?
Consider including a subject heading reflective of this content.4. What diagnostic tests
would be appropriate for this case, and how would the results be used to make a diagnosis?
Consider including a subject heading addressing this content. Patient Assessment:
Gastrointestinal System.SOAP Note Assessment of Patient JR: 47 Years Old, Caucasian, With
Diarrhea and Left Lower Quadrant Abdominal PainAn analysis of the subjective portion of
patient JR's SOAP note reveals that some additional information needed to be added. To be
specific, in the history of presenting illness or HPI the nature of the symptoms is usually
described using the acronym LOCATES. In the SOAP note, some of this has been done.
However, what is missing are the associated factors to the abdominal pain. These would be
the aggravating factors or the alleviating factors to the left lower quadrant (LLQ) abdominal
pain. Also missing is information on the character of the pain. This should have described
whether the pain is sharp or dull, for instance. Lastly on the HPI, the timing of the pain is not
given. It is therefore difficult to establish from the SOAP note whether the pain is
continuous or comes at particular times. The subjective assessment is also missing
information on the immunization history of the patient. Furthermore, there is no review of
systems. This should include all systems and start with the general outlook or constitutional
picture. It should then review the head, eyes, ears, nose, and throat (HEENT). After the head
then should follow the othet body systems such as respiratory, cardiovascular,
integumentary, and so on. Patient Assessment: Gastrointestinal System.In the analysis of the
objective portion of the SOAP note, it is obvious that the patient's body mass index or BMI
has not been calculated, even though his weight and height are presented. Other missing
details are on the diagnostic tests. It is improbable that a patient who presents with
abdominal pain and diarrhea is treated without even a single laboratory test being done.
Patient Assessment: Gastrointestinal System.The assessment is indeed supported by
subjective and objective information in the SOAP note. In gastroenteritis, the most common
and predominant symptoms are usually abdominal cramps, diarrhea, nausea, and a low
grade fever (Hammer & McPhee, 2018; Huether & McCance, 2017). The patient reports in
the subjective portion that he has "pain" in the abdomen. It is possible that what he has are
abdominal cramps. He also reports having diarrhea. In the objective portion, the patient is
found to have a low grade fever which is at 99.8°F. All this goes to support the assessment of
a diagnosis of gastroenteritis or GE (Fletcher, 2018). Patient Assessment: Gastrointestinal
System.Diagnostic Tests and How to Arrive at the Diagnosis The most likely diagnostic tests
that could have been done on patient J.R. include:Stool for microscopyEndoscopyAbdominal
ultrasoundA full blood count (FBC)Taking a stool sample for microscopy would enable the
identification of the microbes responsible for the gastroenteritis infection. This woild have
confirmed the diagnosis beyond any reasonable doubt. Furthermore, it would have enabled
the performance of culture and sensitivity tests to determine the best antibiotics to use.
Endoscopy which involves visualisation of the gut through an inserted tube with a camera
would have helped in ruling out other inflammatory conditions like ulcerative colitis. An
3. abdominal ultrasound on its part would have also played a big part in ruling out the
presence of kidney stones and hernia which are possible differential diagnoses (Fletcher,
2018). Lastly, a full blood count is a standard and should be done, especially because the
patient has a low grade fever. It would reveal any leucocytosis ondicating infection and
point towards the gastroenteritis. Other abnormalities in the blood would also be made
apparent like thrombocytopenia or anemia. Patient Assessment: Gastrointestinal System.To
Reject the Current Diagnosis or NotI would not reject the current diagnosis but accept it
based only on the clinical picture (history and physical examination). The clinical picture
from the subjective and objective parts of the SOAP note indeed have supported in part the
current diagnosis of GE. However, the fact that no diagnostic tests were done must be taken
into consideration. If these were done as explained above, the picture that would have
emerged may have been different as to rule out GE and confirm another different diagnosis.
As such, four very possible differential diagnoses ate likely for this patient. These are:
Patient Assessment: Gastrointestinal System.Crohn's diseaseUlcerative colitisIrritable
bowel syndrome (IBS),Kidney stones, andIntestinal obstruction (Hammer & McPhee, 2018;
Fletcher, 2018; Huether & McCance, 2017).The reasoning behind this is that both ulcerative
colitis and Crohn's disease are inflammatory bowel diseases that also present with
abdominal pain and diarrhea (MFMER, 2019). Irritable bowel syndrome and kidney stones
also are known to present with symptoms that include abdominal pain, diarrhea, nausea,
and vomiting (MFMER, 2018). Any of these conditions could potentially be responsible for
patient J.R.'s symptoms as illustrated in the subjective assessment and confirmed with the
objective physical examination. Patient Assessment: Gastrointestinal System.ConclusionThe
SOAP note for 47 year-old patient J.R. was short and not comprehensive enough. It is clear
that some important details were omitted. These omitted details could have been
instrumental in arriving at the diagnosis or confirming the provisional diagnosis of
gastroenteritis. On the same vein, diagnostic tests done are mot shown anywhere. These are
crucial in any gastrointestinal illness as many co ditioms could mimic what the clinician
thinks is the diagnosis as per the history and physical examination. Patient Assessment:
Gastrointestinal System.
