Assessing the Abdomen - Clinical Methods

Subjective Portion of the Note 

The subjective portion of the note needs more information. One subjective information that is needed is the quality of the pain. Whether the pain is sharp, shooting, or radiating can determine the origin of the pain and which organ is involved (Attard, Corlett, Kidner, Leslie & Fraser, 1992). Another subjective information is the quality of the pain, whether it is intermittent, continuous, or if it precedes any event. This would help determine how the patient perceives the pain and would help in diagnosing the pain (Attard et al. 1992). One crucial data would be how long the patient has been taking metformin. Metformin is known to cause gastrointestinal upsets, especially initially in patients who have been newly-prescribed the drug (Davidson & Howlett, 2004). In addition, the type of metformin should be elucidated. Extended-release metformin is less likely to cause gastrointestinal upsets compared to immediate-release metformin (Davidson & Howlett, 2004). 

Objective Portion of the Note 

Objective data that should be collected include whether the patient has rebound tenderness, Murphy’s sign, and whether a mass is present in the patient. Sweetser (2012) created a five-step approach for diagnosing diarrhea in patients. These are the following steps: first is to establish whether the patient really has diarrhea, which means that fecal incontinence and impaction should be ruled out; the second is to rule out the cause of diarrhea from medications; the third is to establish whether the patient has chronic or acute diarrhea; the fourth is to properly identify whether the diarrhea is watery, fatty, or inflammatory; and lastly, the doctor should rule out factitious diarrhea. These factors should be taken into account in the objective assessment of the patient. 

The Assessment of the Patient 

The assessment is not supported by subjective and objective data because information is lacking about the patient. For instance, a lot of data is lacking from the subjective information provided by the patient. As mentioned, the quality of pain and how the pain is experienced. In terms of objective data, the aforementioned information was lacking from the objective assessment. 

Diagnostic Tests 

The diagnostic tests that would be appropriate for the patient would include colonoscopy, abdominal ultrasound, barium enema, abdominal x-ray, fecalysis, and fecal occult blood test. The results of these tests would help the practitioner arrive at an appropriate diagnosis by showing whether there are soft tissue abnormalities that are associated with the diarrhea or whether other causes, such as colon cancer, diverticulitis, or whether polyps might be present (Barr & Smith, 2014). These tests can help distinguish the causes of diarrhea and can help in understanding the pathophysiology behind the patient’s symptoms. 

Diagnosis and Differential Diagnoses 

The current diagnosis should be rejected. According to Lee et al. (2007), gastroenteritis is usually caused by viruses, such as the norovirus. Since the patient only has a mild fever and no fecalysis was not performed, the presence of viruses and bacteria cannot be established. Three possible differential diagnoses can be colon cancer (Barr & Smith, 2014), fecal impaction (Sweetser, 2012), and irritable bowel syndrome (Davidson & Howlett, 2004). Colon cancer can be a differential diagnosis because it can cause diarrhea due to malignancies in the colon. On the other hand, fecal impaction may also be a cause, especially if the diarrhea is watery or fatty. Lastly, irritable bowel syndrome may also cause diarrhea because the pathophysiology of the disease includes the malabsorption of fluids (Davidson & Howlett, 2004). These differential diagnoses can be considered as a possible cause of the patient’s subjective complaints and may also be the reason for the objective observations. 

References 

Attard, A. R., Corlett, M. J., Kidner, N. J., Leslie, A. P., & Fraser, I. A. (1992). Safety of early pain relief for acute abdominal pain.  BMJ ,  305 (6853), 554-556. 

Barr, W., & Smith, A. (2014). Acute diarrhea.  American Family Physician ,  89 (3). 

Davidson, J., & Howlett, H. (2004). New prolonged-release metformin improves gastrointestinal tolerability.  The British Journal of Diabetes & Vascular Disease ,  4 (4), 273-277. 

Lee, N., Chan, M. C., Wong, B., Choi, K. W., Sin, W., Lui, G., … Leung, W. K. (2007). Fecal viral concentration and diarrhea in norovirus gastroenteritis.  Emerging Infectious Diseases ,  13 (9), 1399–1401. doi:10.3201/eid1309.061535 

Sweetser S. Evaluating the patient with diarrhea: a case-based approach.  Mayo Clin Proc . 2012;87(6):596–602. doi:10.1016/j.mayocp.2012.02.015