Summary Gastrointestinal disorders often present with vague and non-specific symptoms. For this reason, health care providers need to gather a complete health history as well as a comprehensive physical examination to be able to make a diagnosis. The case study that was presented was a 47-year-old white male that was complaining of a stomach ache with
ASSESSMENT 8 nausea and diarrhea. The SOAP note included some subjective data, objective data, and an assessment which stated that the patient had left lower quadrant pain and a diagnosis of gastroenteritis was initially given. Additional subjective information can be gathered by asking questions like did you travel to another state or country within the past week, or have you been in contact with similarly ill people? Further objective data can be gleaned by performing examinations like assessing for McBurney’s sign and Murphy’s sign. The subjective and objective information are not enough to definitively make a diagnosis of gastroenteritis; therefore, this diagnosis was rejected. Diagnostic tests that may be pertinent for this case include stool testing, complete blood count, abdominal and pelvic ultrasound, and abdominal and pelvic CT. Finally, differential diagnoses of acute sigmoid diverticulitis, irritable bowel syndrome, and infectious colitis were identified as possible conditions for the patient based on his symptoms using current evidence-based- literature. References Boyce, T.G. (2017). Overview of gastroenteritis. Merck Manual Professional Version . Retrieved from / gastroenteritis/overview-of-gastroenteritis Kalakonda, A., Garg, S., Tandon, S., Vinayak, R., & Dutta, S. (2016). A rare case of infectious colitis. Gastroenterology Report , 4(4), 328 – 330. Retrieved from gastro/article/4/4/328/2568565
ASSESSMENT 9 Huether, S.E., & McCance, K.L. (2017). Understanding Pathophysiology (6 th ed.). St. Louis, MO: Mosby. Lehrer, J.K. (2018). Irritable bowel syndrome clinical presentation. Medscape . Retrieved from W5HmI95BCVFnH%2FQhe6iq0%2B6WXFv1GMzky6GXELlgKrns56MI7dGTgNawPfs OtJla9Q%3D%3D Mazzei, M. A., Cioffi Squitieri, N., Guerrini, S., Stabile Ianora, A. A., Cagini, L., Macarini, L., … Volterrani, L. (2013). Sigmoid diverticulitis: US findings. Critical Ultrasound Journal , 5 (Suppl 1), S5.
- Summer '15