This assignment aims at distinguishing a variety of medical conditions which appear to be similar in terms of signs and symptoms, on a 47-year-old patient complaining of prolonged abdominal discomfort. The paper will analyze both the subjective and objective portions of the SOAP notes and as well provide the diagnosis tests that are most appropriate in determining the patient’s diagnosis.
The patient is 47 years old whose chief complaint is stomach pains, the onset of diarrhea which has been going on for 3 days. The patient appears well nourished, that is, he looks healthy and strong physically. He has not been under any medication since the pains started but has subsided from its severity when it started, from 9/10 to a 5/10 ratio. According to his medical history, there are recorded cases of Hypertension, Diabetes and Gastrointestinal bleeding dating back to four years ago. The patient has no record of allergic reaction to any drug that has been administered to him in the past.
As required during a medical diagnosis, the physician has to take a look at the family history of the patient. When the health history of the family was examined, there was absence of cases of colon cancer which could have been one of the possible reasons for the abdominal pains. The absence of colon cancer in the family history however does not rule out the possibility of its diagnosis on the patient, it only lowers the risk of its possibility since cancer can be hereditary. The records also showed that the patient’s father had a history of Diabetes Type 2. In medicine, this is a risk factor for the patient and therefore Diabetes Type 2 was documented as one of the illnesses to be examined in the patient. Both the mother and the father to the patient also had a history of Hypertension which also could be among the risk factors during the diagnosis of the patient. The mother had a history of Hyperlipidemia and GERD which were both recorded for further examination on the patient. The social life of the patient was considered healthy since there was no record of tobacco, however there was occasional drinking which could cause other health problems that could affect the abdomen. The patient has three children and wife which would prompt the physician to make an analysis of the family relations within his household which would elevate the risk of his illness such as stress levels. The family financial status should therefore be examined in order to enhance the diagnosis since financial constrain with a large family like that of the patient could lead to stress. The marital stability status should also be examined to determine its contribution to the patient’s health status.
After an examination by the physician, the patient’s vital signs were as follows; the temperature was at 99.80 F. The normal temperature of the human body ranges between 97.80 F-990 F which means that the patient’s body temperature was within range. His blood pressure was at 160/86 whereas the normal blood pressure should be at 120/80. The patient exceeded the normal blood pressure, his systolic was at stage 2, it was higher than 140 which is a warning sign and the diastolic was at stage 1 falling between 80-89. This was an alarming sign which was recorded as a risk factor for several illnesses especially those related with stress. His respiration rate was within range falling between the 12-16 range, at 16 breaths per minute. His pulse rate which represents both the strength of the pulse and the heart rhythm was at 92beats per minute which was within the normal 60-100. His Body mass index was way above normal at 36.9 and the patient was considered obese, obesity is declared at BMI greater than 29.9. Other tests on the heart rate we normal, his lungs were functional and his skin was in good condition with no abnormalities detected. When his abdomen was examined, softness, hyperactivity in the bowel accompanied by sounds, and pos pain in his left lower quadrant was recorded. The physician should have examined his Body Mass Index which, with the given height and weight, was way above normal at 36.9 and the patient was alarmingly obese, obesity is declared at BMI greater than 29.9.
Nature of the assessment
The medical assessment was supported more by the objective information since those were the verifiable facts during the patient’s diagnosis. In the subjective assessment, the patient appeared well nourished, and denying intake of tobacco and occasional intake of alcohol were subject to bias. It is only through the objective assessment that high blood pressure and obesity were detected which created room for more informed diagnosis.
Besides taking the patient’s health history, physical examination would be very essential which would include tests such as palpation. Palpation would require the physician to gently exert pressure on various parts of the abdomen to assess tenderness and pain. The presence of pain on a certain part like the left lower quadrant would help the physician make a variety of diagnosis related to the digestive tract, abdominal wall muscles, blood vessels and the patient’s reproductive organs. A lab test could also be conducted where an Occult Stool would be used to check for blood in the stool. The patient had complained of diarrhea which would make the test appropriate in checking for signs of infection in the stomach. CT scan on the lower abdomen would be very essential in the diagnosis as they are more precise on where the illness could be (Mendelson, 2015).
Possible differential diagnosis
One of the possible differential diagnosis is the presence of Crohn disease characterized by abdominal pain with bloody diarrhea. The patient could also be suffering from Ureterolithiasis which is characterized by colicky pain which may be progressive then turning to constant. The patient reported the pain to have been severe at first then lowered with time, which could be caused by the body tolerating to the pain. The other symptom of ureterolithiasis is pain in the lower abdomen which was detected in the patient’s lower left quadrant (Dains et al., 2015).
The other possible condition could have been Incarcerated hernia which is characterized by severe pain in either the RLQ or the LLQ as detected in the patient. Obesity may result to intestinal obstruction where the intestines are blocked and may result to the abdominal pains experienced by the patient as well as diarrhea (Sharma et al, 2017). The fat is causes the blocking on blood vessels and may lead to high blood pressure which is common among obese people. The patient exceeded the normal blood pressure, his systolic was at stage 2, it was higher than 140 which is a warning sign for hypertension (Afolabi, & Guo, 2014).
Afolabi, J., & Guo, H. (2014). Guiding Hypertensive Adult Patients: A Literature Review of Evidence-Based Nursing.
Dains. E. J., Baumann L.C., & Scheibel P., (2015). Advanced Health Assessment and Clinical Diagnosis in Primary Care. 5th Edition. ELSEVIER, 30(5), 236-237.
Mendelson, R. (2015). Diagnostic tests: Imaging for chronic abdominal pain in adults. Australian prescriber, 38(2), 49.
Sharma, L., Srivastava, H., Pipal, D. K., Kothari, S., Dhawan, R., & Purohit, P. M. (2017). Acute intestinal obstruction: small intestine vs. large intestine: an analysis. International Surgery Journal, 5(1), 162-167.
Yang, X. F., & Liu, J. L. (2014). Acute incarcerated external abdominal hernia. Annals of translational medicine, 2(11).