Assessing the Abdomen

Analysis of the Subjective Note 

The subjective portion of the note suggests that the patient has been experiencing pain in his stomach and diarrhea. These symptoms are associable with various illnesses and conditions. Likewise, the simultaneous concurrence of the two may result from a variety of factors such as viral infections, indigestion, or intestinal diseases. Thus, it is vital for the patient to pinpoint the causes of the observable signs to guide in prescribing the appropriate medication, diagnosis, or home remedies and tips. Also, the documentation includes a medical history of the patient as well as the family predispositions that may be helpful in administering effective care. It is worth contemplating that while this information may shed sufficient light on what is ailing the patient, subjective information is usually prone to inaccuracies and bias, which may inhibit the provision of the proper medical care. In essence, getting an objective view of the patient’s ailment helps in providing the most fitting health care

There exists several additional information that should be included in the documentation. First, the caregiver should assess and record the patient’s skin pigmentation and color. For instance, the presence of a blueish color at the umbilicus could be a symptom of the perineum. Also, there is a need to establish the existence of scars which may imply that an earlier incidence related to the injury may have caused internal scarring, thereby resulting in intestinal obstruction. Also, it is advisable to inspect nodules or lesions as they may signify a gastrointestinal disease (Brown & Suvarna, 2016).

Another important piece of information is the peristalsis movement accords the abdomen. While peristalsis is a common phenomenon during the entire digestion process, it is not usually visible at the abdomen’s surface. Thus, any obvious movement may be a symptom of intestinal obstruction.

Sounds are also crucial when documenting the abdomen assessment. Usually, healthcare providers establish most of these sounds using the stethoscope. The Borborygmi, high-pitched, and friction rub sounds are audible using the stethoscope’s diaphragm. Contrariwise, the bell can enable one to listen to aortic bruits, iliac or femoral bruits, renal artery bruits, and venous hum sounds. These noises are crucial in establishing aspects ranging from the peritoneal surface inflammation, obstructions in the intestines, abdominal aortic aneurysm, stenosis, or respiration among other useful factors.

Use of Subjective and Objective Information in the Assessment 

The assessment is relatively supported by both subjective and objective information. The data obtained from the patient’s recollection of his past encounters have helped in establishing causality in the abdominal assessment. Also, the information aids in conducting an effective observation before proceeding with the sequential objective evaluations. The data shows a substantial inspection of the abdomen. For instance, the examination considers aspects such as symmetry in the chest wall and the heart rate. An effective assessment must inculcate the information provided by the patient as well as the caregiver’s own impartial observation through tests and diagnostics such as palpation, auscultation, and percussion.

Appropriate Diagnostic Tests 

As aforementioned, several diagnostic tests will be essential in establishing an objective examination of the abdomen. First, it crucial to carry out auscultation, which involves establishing the existence of abnormal sounds around the abdomen. Decreased sounds signify low gut activity, which may result from abdominal surgery or infection as well as injury (Du et al., 2018). Ischemia and obstruction of the intestines may cause such a decrease. Second, a nurse should administer a percussion; a procedure that helps in identifying the resonance, tympany, and dullness in the abdomen. Percussion involves the skillful use of fingers on the abdomen’s four quadrants, bladder, and the spleen. One may also percuss the kidneys by using the ulnar surface to strike the non-dominant hand placed on the patient’s left costovertebral angle. However, precaution should be taken when administering the kidney percussion in that the patient may be tired of previous percussions.

Additionally, it is vital to initiate palpation, which entails depressing the abdominal wall while looking for areas of tenderness as depicted by the patient’s facial expression. Palpation also involves identifying any abdominal guarding and masses. The latter entails areas of deep tenderness as established while palpating. At this point, the patient may exhibit a ticklish behavior, in which case it is helpful to place one’s hand on his hand. Also, the hooking technique is recommended when dealing with obese patients (Schiff, Maddrey & Reddy, 2017).

The Credibility of Current Diagnosis 

The current diagnosis is fairly meaningful and thus acceptable for various reasons. Crucially, it accounts for both the subjective and objective data, thereby acknowledging the importance of the synergy between the two. Also, the diagnosis includes some vital procedures such as auscultation and palpation. Also, an examination of the lings and the heart is present which strengthens the reliability of the gathered data.

Possible Conditions that May Be Considered as A Differential Diagnosis for this Patient 

The three possible conditions associable with the diagnosis based on the information gathered thus far are appendicitis, gastric ulcer, and inguinal hernia. The hyperactive bowel sounds observed in the lower abdomen may signify the existence of appendicitis. The gastric ulcer occurs in the right side of the upper abdomen and is mostly attributed to abdominal pain (Ng, Lee & Foo, 2017). Lastly, an inguinal hernia is a condition that chiefly affects men and causes pain in the left lower quadrant as reported in the objective assessment.

References

Brown, S. C., & Suvarna, S. K. (2016). Gastrointestinal and Hepatobiliary System. In  Atlas of Adult Autopsy  (pp. 161-190). Springer, Cham.

Du, X., Allwood, G., Webberley, K., Osseiran, A., & Marshall, B. (2018). Bowel sounds identification and migrating motor complex detection with low-cost piezoelectric acoustic sensing device.  Sensors ,  18 (12), 4240.

Ng, C. Y., Lee, S. L., & Foo, S. L. (2017). Perforated gastric ulcer in severe dengue infection: A case report.  Med J Malaysia ,  72 (4), 244-5.

Schiff, E. R., Maddrey, W. C., & Reddy, K. R. (Eds.). (2017).  Schiff's Diseases of the Liver . John Wiley & Sons.