It is essential to collect detailed subjective history to narrow down to diagnoses that are more accurate. The current subjective history is insufficient, and it could have been improved if the practitioner had asked more targeted questions about his pain. First, the practitioner should have asked the patient to explain how the pain started. It is crucial to understand if the pain started gradually or suddenly. Moreover, it is important to investigate the quality of pain to visualize what is happening in the abdomen. For instance, a poorly localized ache is linked with visceral peritonitis, while colicky pain occurs due to forceful peristaltic contractions (Dains et al., 2016). Additional information could have been gathered if the patient was asked to explain his bowel movements. According to Ball et al. (2015), the frequency, characteristics, smell, color, and consistency of the bowel movement indicate the processes in a person’s bowel. For instance, Ball et al. (2015) explained that loose, frequent, and strong-smelling diarrhea is an indicator of Helicobacter pylori (H. Pylori), which can necessitate stool testing for the bacterium. Thus, asking targeted questions could have significantly enhanced the diagnoses presented in the current case.
The objective assessment was adequate, as there are positive findings in the abdominal assessment. Nevertheless, Ball et al. (2015) indicate that the assessment could have been enhanced if the practitioner investigated whether the abdomen was distended by measuring its girth to find out if it was enlarged. Although the assessment was adequate, it is not right for practitioners to assume some minor assessment procedures such as percussing the abdomen as they can help in enhancing the accuracy of the diagnosis.
The information given supports the current assessment as the heart rate, temperature, and blood pressure are slightly higher due to the 5/10 pain that the patient was experiencing when the evaluation was done. The patient stated that he has diarrhea, which corresponds to the hyperactive bowel sounds (Dains et al., 2016). There is tenderness in the left lower quadrant (LLQ), but it is unrelated to the generalized pain experienced by the patient. However, the pain might be originating from the LLQ and spreading towards the other non-tender quadrants.
To rule out electrolyte imbalances, parasitic infections, and other possible infections as the sources of pain, a series of lab tests should be done when collecting diagnostic data. Some of the tests that should be done, according to Leblond et al. (2014), include the clostridium difficile stool (C.Diff), complete metabolic panel (CMP), and a complete blood count (CBC). Leblond et al. (2014) explained that more tests should be done there if a higher white count from the CBC test as it indicates that an infectious process is taking place. Moreover, Pylori infection will be ruled out by testing for C. Diff, and occult stool will tell if there is any bleeding in the intestine.
It is reasonable to accept the current diagnosis as the patient’s subjective data corresponds with abdominal pain, nausea, and diarrhea. The LLQ tenderness is indicative of a major inflammation, which is responsible for elevated temperature. The three possible diagnoses for the patient are Ulcerative Colitis, Sigmoid Diverticulitis, and Regional Ileitis. The patient has a history of GI bleeding, which is related to Ulcerative Colitis and can explain the rise in body temperature, diarrhea, and pain. Symptoms such as LLQ pain, diarrhea, and higher temperature are also related to Sigmoid Diverticulitis. Finally, Regional Ileitis is an inflammation of the intestine, and it can raise body temperature, LLQ pain, vomiting, nausea, and diarrhea.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). Elsevier Mosby.
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). McGraw Hill Medical.