Subjective Portion
The subjective portion of the note lacks some crucial information. Generalized abdominal pain should be addressed in a detailed manner to determine the possible diagnoses from the vast of those characterized by this symptom. In the HPI section, there is data of the patient’s age – 47 years old with generalized abdominal pain started 3 days ago. The patient has not taken any medications. The pain intensity is 5/10 on the day of the appointment, 9/10 on the first day. The patient can eat with some nausea afterward. The note’s subjective portion contains information on the patient’s past medical history. He has hypertension, diabetes, GI bleeding 4 years ago. Medications taken are Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs. The patient reports no known drug allergies, no colon cancer. Father was diagnosed with DMT2, HTN; mother had HTN, Hyperlipidemia, GERD. Social history includes the absence of tobacco use, occasional EtOH. The patient is married, has a girl and two boys.
Concerning the additional information, it is necessary to define a pain’s character, whether it is dull, stabbing or aching. There are no details of temporal patterns, referring to the presence or absence of set patterns, such as every evening or morning. Moreover, some alleviating factors are helpful to determine what reduces or worsens symptoms. Furthermore, the note should include data if there are any symptoms associated. The patient should narrow the location of the pain from the stomach to a more precise location.
Objective Portion
The objective portion of the note should be more informative regarding the patient’s general appearance. It reports on temperature 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs. The heart system is characterized by RRR, no murmurs; the chest wall is symmetrical. Skin is intact without lesions; there is no urticaria. The abdomen is soft with hyperactive bowel sounds and pain in the LLQ. There is no data on the result of the inspection and percussion of the abdomen. This part of the note should contain an assessment of eyes, ENT/mouth, musculoskeletal, neurological and psychiatric systems. This can provide additional information on abdominal pain and its origins. Besides, there is no complete blood count (CBC), skin pallor, cap refill. As the patient has diabetes, blood glucose and comprehensive metabolic panel (CMP) should also be analyzed. Concerning the abdominal, LLQ palpation’s character is required. Additional tests are Abd x-ray, HbA1c, stool WBC and stool guaiac.
Assessment
The assessment is supported mainly by subjective data as the diagnosis is principally provided based on the patient’s complaint. It informs on LLQ pain with the diagnosis – gastroenteritis. The symptoms of gastroenteritis are usually diarrhea, fever, nausea, stomach pain, cramping and headache. The objective portion of the note is not considered due to a lack of information and insufficient investigation. Generalized pain reported by the patient and left lower quadrant (LLQ) pain are different; however, the latter is disregarded. It should be screened as it is the symptoms of several acute diseases that should be addressed immediately.
Diagnostic Tests
First, CBC and CMP are required due to the patient’s low-grade fever to determine the infection risk. Furthermore, the patient should undergo an ultrasound of the abdomen to see all abdominal organs. Another diagnostic test is the stool occult test, examining the presence of blood in the stool to eliminate the problems with the upper digestive tract. It is necessary to conduct a complete blood count and analyze electrolytes’ content, urea nitrogen and creatinine in the blood. To exclude the possible atypical presentation of acute appendicitis, it is recommended to perform abdominopelvic computed tomography (CT) scan, accompanied by IV and oral contrast agents (Seyedhosseini-Davarani & Akhgar, 2018). In case CT reveals pericycle mesenteric fat inflammation, blind loop thickened appendix, the patient will be diagnosed with acute appendicitis (Seyedhosseini-Davarani & Akhgar, 2018). Therefore, he should undergo surgery as quickly as possible.
Possible Conditions
As there is insufficient data on the patient’s symptoms and conditions, the current diagnosis should be rejected. The first differential diagnosis that can be considered is appendicitis. The appendicitis symptoms are diarrhea, nausea, and vomiting. Pain might constantly be moving; it can occur in the upper abdomen, migrate to the left or right side, give to the ribs or anus (Seyedhosseini-Davarani & Akhgar, 2018). Depending on the cecum and appendix location, patients with acute appendicitis and malrotation may show an atypical picture of appendicitis with left-sided abdominal pain (Kong et al., 2019). A CT scan is required, revealing intestinal malrotation, which determines an unusual clinical picture of appendicitis.
Second, it might be ulcerative colitis, as one of its symptoms is diarrhea. Patients can also report a false urge to have bowel movements, bloating and pain in the left abdomen (Rubin et al., 2019). In the patient’s case, it might be left-sided colitis. The diagnosis should be based on a combination of endoscopic, clinical, radiological and stool test results (Sahami et al., 2017). C-reactive protein may raise with the likeliness of iron deficiency anemia; leukocytes and platelets are also increased (Sahami et al., 2017). The primary diagnostic method is colonoscopy – an endoscopic examination of the large intestine.
The third diagnosis might be clinically uncomplicated colonic diverticulosis. The main symptoms are abdominal pain and bowel dysfunction (Tursi et al., 2020). They are often localized in the lower abdomen, especially in the left iliac region (Tursi et al., 2020). Diarrhea is sometimes noted; patients complain of unstable stools (Tursi et al., 2020). The described symptoms are combined with nausea or vomiting (Tursi et al., 2020). Differential diagnosis of colon diverticulosis is based on an analysis of the disease’s clinical manifestations and the results of mandatory X-ray and endoscopic studies of the colon.
References
Kong, F. B., Dong, C. C., Deng, Q. M., Wang, X. T., & Deng, H. Q. (2019). Left-sided acute appendicitis: A case report and a review of literature. Indian Journal of Surgery, 81(1), 65-69. Web.
Rubin, D. T., Ananthakrishnan, A. N., Siegel, C. A., Sauer, B. G., & Long, M. D. (2019). ACG clinical guideline: Ulcerative colitis in adults. American Journal of Gastroenterology, 114(3), 384-413. Web.
Sahami, S., Konté, K., Buskens, C. J., Tanis, P. J., Löwenberg, M., Ponsioen, C. J., & D’Haens, G. R. (2017). Risk factors for proximal disease extension and colectomy in left-sided ulcerative colitis. United European Gastroenterology Journal, 5(4), 554-562. Web.
Seyedhosseini-Davarani, S., & Akhgar, A. (2018). Atypical presentation of acute appendicitis: A 32-year-old man with gastroenteritis symptoms; An educational case. Advanced Journal of Emergency Medicine, 2(2). Web.
Tursi, A., Scarpignato, C., Strate, L. L., Lanas, A., Kruis, W., Lahat, A., & Danese, S. (2020). Colonic diverticular disease. Nature Reviews Disease Primers, 6(1), 1-23. Web.