2. Analyze the objective portion of the note. List additional information that should be included in the documentation. 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 : None Additional information that should be included in the objective portion of the documentation is pertinent for accurate diagnosis. The provider should note the patient’s general appearance. Patients with visceral pain are restless and have difficulty getting comfortable, these are patients with colicky type pain that is often indicative of obstruction, gastroenteritis, or early peritonitis (Dains, Baumann, and Scheibel, 2016). Patients with parietal pain usually lie still and do not want to move, these are patients with localized peritonitis indicative of appendicitis, rupture, or perforation (Dains, et al., 2016). Abdominal skin coloring should be assessed to determine diagnosis. Ecchymosis around the umbilicus (Cullen Sign) is associated with hemoperitoneum caused by pancreatitis (Dains, et al., 2016). Abdominal distension should also be included in the documentation. Asymmetrical distension or protrusion may indicate hernia, tumor, cysts, bowel obstruction, or enlarged abdominal organs (Dains, et al., 2016). Percussion tones should be included and testing for rebound tenderness would be pertinent information. Tenderness, guarding, and rebound tenderness suggest peritoneal irritation (Dains, et al., 2016). Abrupt cessation of inspiration on palpation of the gallbladder (Murphy sign) indicate acute cholecystitis (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Palpation of any masses would also be an important assessment in JR which may indicate neoplasm, obstruction, hernia, or the presence of feces in the colon (Dains, et al., 2016). A genitourinary assessment should be documented in order to rule out renal or urinary processes; flank pain, dysuria, hematuria etc. should be noted. A genital/rectal exam would also be pertinent in this case study. The groin must be examined in everyone who has abdominal pain to exclude an incarcerated hernia. Also, the diagnostics portion belongs in the assessment documentation, not the objective data. 3. Is the assessment supported by the subjective and objective information? Why or Why not?
- Summer '15
- Gastroenterology, Dains