Subjective data entails the data received first hand from the patient.
generalized abdominal pain.
Pain intensity (mild, moderate, severe)
Sudden or Gradual
When the pain started and what was here activity then
Her urinary habits
Her bowel motility
Additional Information that Should Be Included in the Documentation of Objective Data
Both physical and abdominal checkup.
Heart beat rate
Patient’s general appearance
Her mental status
Jaundice
Previous health History
Whether the Assessment Is Supported by the Subjective and Objective Information
From the assessment, the patient has a left lower quadrant pain and gastroenteritis. From the subjective and objective information obtained, the assessment is well supported . When the enzymes within the pancreases are unable to secrete enough pancreatic juice, the patient with pancreatic cancer experience diarrhea because of indigestion. The pain in the lower left quadrant and the patient’s revelations denotes gastroenteritis (Colyar, 2015).
Most Appropriate Diagnostic Tests for This Case
A complete blood diagnostic would be an appropriate test in this case .Also a liver test would be appropriate. Patient who suffer from pancreatic cancer have thrombocytosis when a full blood count is performed. High levels of bilirubin, serum amylase and lipase will be observed when a liver test is observed denoting obstructive jaundice .the vastly recommended imaging to be used here would be the CT scan as compared to the MRI. This is because the CT scan gives an image of the whole pelvis and stomach (Ball, Dains,Flynn, Solomon & Stewart, 2019).
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Accept the diagnosis
As already confirmed by the CT scan, it is most probable that the patient suffers from pancreatic cancer. Most patients who suffer from similar condition express mild to severe pain in the upper abdomen that may manifest to the back, which radiates to the back, jaundice, diarrhea and weight loss. When the pancreas is unable to secrete enough juice, the digestive process is hindered resulting to indigestion. Because of the diagnosis, it is evident that I accept the current diagnosis. The potent differential diagnoses include Acute mesenteric ischemia , pancreatic lymphoma, Appendicitis and Cholecystitis (Colyar, 2015).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
