The patient presented with a 2-day history of intermittent epigastric abdominal pain that radiated to his back. His vital signs were abnormal. On examination, his abdomen was tender in the epigastric area with guarding. The assessment of AAA, perforated ulcer, or pancreatitis may be premature without further diagnostic testing. Additional history regarding risk factors, medications, and bowel habits is needed. Further objective examination of other body systems and diagnostic testing such as ultrasound or CT would help support or rule out potential diagnoses. Differential diagnoses to consider include peptic ulcer disease, cholecystitis, or myocardial ischemia.

1. 2
Case Study Analysis Assessment of the Abdomen and
Gastrointestinal System
Student
School
Professor
Course
Date
Case Study Analysis Assessment of the Abdomen and
Gastrointestinal System
Additional information that should be included in the
documentation of subjective data
When a healthcare professional receives subjective data, the
patient's perspective is considered. This way encompasses all
the worries, sentiments, and impressions that are gleaned during

2. interviews. Abdominal discomfort was the patient's primary
complaint in the scenario, making it crucial to have information
regarding the quality and location of the pain, whether it is
migratory, localized, increases or decreases in severity, or
where it comes from and radiates outward. In addition, it is
essential to note if the discomfort started suddenly or gradually.
The patient should be questioned about what he was doing at the
time when the discomfort began. It is impossible to overstate
the significance of figuring out what is causing the pain and
what is helping to relieve it. Several possible diagnoses may be
narrowed down using this information (Ball, Dains, Flynn,
Solomon, & Stewart, 2019).
It's essential to have a complete picture of the patient's bowel
and urine routines, even if they only mentioned diarrhea.
Included in this information are the frequency and length of
episodes, the elements that alleviate or exacerbate the
condition, and any other symptoms that may accompany
diarrhea. Additional information on urinary behaviors such as
incontinence, hesitation, dysuria, or urgency should also be
provided. It is essential to detail the odor, color, and pain after
or during the bowel movement. Poop lightening and urine
darkening are common symptoms that can bring light to
differential diagnoses like hepatitis. (Ball, Dains, Flynn,
Solomon, & Stewart, 2019). In order to rule out other possible
symptoms, such as nausea and vomiting, it is essential to look
into the possible causes of stomach discomfort.
The patient had a history of gastrointestinal bleeding four years
earlier. There should be information on whether vomitus or
stool has blood in it and its color and smell. There should be
some information on his medication compliance as he takes
medicine for hypertension and diabetes. In order to assess the
likelihood of abdominal damage, it is necessary to incorporate
information about the patient's profession.
Additional information that should be included in the
documentation of objective data
Different systems must be examined to get a comprehensive and

3. thorough evaluation of a complaint of abdominal discomfort.
Following a complete visual assessment, the examiner will do
an abdominal exam that includes auscultation, percussion, and
palpation while keeping a close eye on the patient for any signs
of resistance, grimacing, or recoiling. To rule out other urgent
diagnoses like testicular torsion or an incarcerated hernia which
can be discarded by doing a deeper examination of the groin and
the genital region (Ball, Dains, Flynn, Solomon, & Stewart,
2019). A percussive examination of the flank may rule out renal
calculi, and additionally search for frank urinary bleeding can
bring a hint. The lungs, heart, head, neck, and musculoskeletal
system may also be examined since stomach discomfort might
be referred from other locations (Dains, Linda, Baumann, &
Scheibel, 2019).
Whether the assessment is supported by the subjective and
objective information
According to the evaluation, the diagnosis in this patient is left
lower quadrant discomfort and gastroenteritis. Both the
subjective and objective evidence strongly supports this
conclusion. The client presented complaints of pain in the left
lower quadrant, which is somewhat corroborated by a symptom
of widespread abdominal discomfort and diarrhea but not
vomiting. The rating of pain level is missing from the patient
history, but the vital signs are slightly elevated, which means
the level of pain is moderate because the heartbeat is higher in
severe pain.
Another meaningful sign is the abdomen which, even with pain,
is soft, meaning that no acute severe pathology like appendicitis
is established (Vaghela & Shah, 2017). The ileum, rectum, left
ureter, and certain colon sections are in the left iliac fossa.
Gastroenteritis was likely to blame for the patient's left lower
quadrant discomfort and principal diagnosis because it is one of
the most frequent abdominal pathologies (Stuempfig & Seroy,
2022).
Most appropriate diagnostic tests for this case and how results
would be used in making a diagnosis

4. A complete blood count (CBC) with differential to evaluate the
possibility of sepsis as a cause, a complete metabolic profile
including liver and kidney functions tests, urinalysis, and
coagulation panel are some laboratory tests that can be used in
the diagnosis of acute abdominal pain. An abdominal CT scan
can be beneficial to discard other acute pathologies or
neoplastic problems, pelvic ultrasound, or radiographic
investigations that can show the colon's inflammation evidenced
by gases level. These tests are imperative to identify the
appropriate diagnosis (Vaghela & Shah, 2017).
Whether I would accept/reject the current diagnosis
This case study's results include discomfort and gastroenteritis
in the left bottom quadrant. The assessment is based on the
physical examination results and the diagnosis of gastroenteritis
as a possible cause of lower quadrant discomfort.
Gastroenteritis symptoms, such as diverticulitis and colitis, are
common. As a result, there is no evidence to support the
conclusions drawn from this assessment as part of an evaluation
segment inside a soap note. Lab findings, diagnoses, differential
diagnoses, existing co-morbidities, and a plan to touch base on
a precise diagnosis or analysis should have been mentioned in
this section (Stuempfig & Seroy, 2022). A few differentiating
analyses would be essential from the most implausible to the
least improbable. If the assessment information is unclear, it is
required to integrate these methods since this section is where
the subjective evidence combines with the objective evidence to
come up with a solid result.
Possible differential diagnoses
The most common diagnosis, gastroenteritis, may have been
diagnosed if the SOAP data is correct. Stomach discomfort,
diarrhea, and nausea may also be linked to a range of diseases,
including gastroenteritis, diverticulitis, colitis, and appendicitis
(Ball et al., 2019). We suspected diverticulitis or unusual
appendicitis when the patient had left lower quadrant pain. It
can be later confirmed upon examination with laboratory and
imaging results. Diverticulitis is very rare in persons under the

5. age of 40 years old (Stuempfig & Seroy, 2022). Atypical left
appendicitis (LSAA) affects males 1.5 times more often than
women, and it typically strikes between the ages of 8 and 64
(Dains et al., 2019). Celiac disease, Crohn's disease, H-Pylori,
and ulcerative colitis are all examples of upper abdominal
conditions that might indicate colitis (Vaghela, & Shah, 2017).
References
Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart,
R. W. (2019).
Seidel's guide to physical examination: An
interprofessional approach (9th ed.). Elsevier.
Dains, J. E., Linda Ciofu Baumann, & Scheibel, P. (2019).
Advanced health assessment and clinical diagnosis in
primary care (6th ed.). Elsevier.
Stuempfig ND & Seroy J.(2022). Viral Gastroenteritis. In:
StatPearls. Treasure Island (FL). Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK518995/
Vaghela, K., & Shah, B. (2017). Diagnosis of Acute
Appendicitis Using Clinical Alvarado Scoring System and
Computed Tomography (CT) Criteria in Patients Attending
Gujarat Adani Institute of Medical Science - A Retrospective
Study.
Polish journal of radiology, 82, 726–730.
https://doi.org/10.12659/PJR.902246

6. The Episodic Note Case Study: Abdominal Assessment
This is the HALF WAY POINT!
LAB ASSIGNMENT: ASSESSING THE ABDOMEN
A male went to the emergency room for severe mid-epigastric
abdominal pain. He was diagnosed with AAA; however, as a
precaution, the doctor ordered a CTA scan.
Because of a high potential for misdiagnosis, determining the
precise cause of abdominal pain can be time consuming and
challenging. By analyzing case studies of abnormal abdominal
findings, nurses can prepare themselves to better diagnose
conditions in the abdomen.
In this Lab Assignment, you will analyze an Episodic note case
study that describes abnormal findings in patients seen in a
clinical setting. You will consider what history should be
collected from the patients as well as which physical exams and
diagnostic tests should be conducted. You will also formulate a
differential diagnosis with several possible
Review the Episodic note case study BELOW.
ABDOMINAL ASSESSMENT
Subjective:
CC: "My stomach has been hurting for the past two days."
HPI: LZ, 65 y/o AA male, presents to the emergency department
with a two days history of intermittent epigastric abdominal
pain that radiates into his back. He went to the local Urgent
Care where was given PPI’s with no relief. At this time, the
patient reports that the pain has been increasing in severity over
the past few hours; he vomited after lunch, which led his to go
to the ED at this time. He has not experienced fever, diarrhea,
or other symptoms associated with his abdominal pain.
PMH: HTN
Medications: Metoprolol 50mg
Allergies: NKDA
FH: HTN, Gerd, Hyperlipidemia

7. Social Hx: ETOH, smoking for 20 years but quit both 2 years
ago, divorced for 5 years, 3 children, 2 males, 1 female
Objective:
VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: abdomen is tender in the epigastric area with guarding but
without mass or rebound. Diagnostics: US and CTA
Assessment:
Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis
THE ASSIGNMENT
1. Analyze the subjective portion of the note. List additional
information that should be included in the documentation.
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.
6. This should be a paper with subheadings, please use
subheadings below. This makes your papers a lot easier to read
and ensures you are answering all the questions on the Rubric.
Be sure to answer all information to receive maximum points.
Subjective Portion
Objective Portion
Assessment Supported
Diagnostic Tests
Rejection or Acceptance

8. Possible Conditions
This should be written as a narrative/paragraph only