Assessing the Abdomen
SUBJECTIVE:
CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago,
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Additional subjective data listed below:
Health history- diet & exercise
General–Negative for fevers, chills, night sweats, and fatigue
Cardiovascular– HTN, denies chest pain and palpation
Gastrointestinal–Positive for diarrhea, and abdominal pain. Negative for vomiting. Bowel movement changes (frequency, regularity, color, and consistency), Bloody stools, rectal bleeding.
Pulmonary—Negative for dyspnea on exertion, congestion, shortness of breath, or cough.
PMH: 1 GI surgery and 1 hospital stay related to GI bleed
- Additional subjective data should include: negative dysphagia, rebound tenderness, tension to muscles, restlessness, change in digestion, presences of hematemesis, exacerbation of the abdominal pain, what relieves the pain, and presence of any mass.
OBJECTIVE:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
Additional objective data listed below:
Additional objective data should include: imbalance of electrolyte, guarding the abdominal area, or vomiting. Inspection (Abdomen is symmetric bilateral, inverted, midline umbilical), no discoloration noted to skin, negative hernia.
General–Pt appears anxious and presents with guarding to abdomen
Cardiovascular-Negative for murmur, cyanosis, and clubbing of fingers.
Gastrointestinal–Abdomen is soft and symmetrical, negative for distention; bowel sounds are hyperactive, Negative for masses, lesions, or splenomegaly. Denies indigestion, or heartburn.
Pulmonary– LCT and percussion bilaterally
Diagnostics: include stool occult test, colonoscopy, liver function test, CT scan, or a biopsy.
ASSESSMENT:
Left lower quadrant pain
Differential Diagnosis includes:
- Gastroenteritis
- Diverticulitis- Pain to the LLQ of the abdomen is the main presenting complaint of diverticulitis, along with systems of diarrhea, vomiting and changes to bowel routine (Shahedi, 2017).
- Chron’s – can be responsible for inflammation of the digestive tract, which can cause symptoms such as abdominal pain, bloody stools, loss of appetite, and severe diarrhea (Mayo Clinic, 2018).
- Colon Cancer – occurs when a malignant tumor forms in the inner wall of the large intestine. Symptoms include pain to the abdominal area, changes of bowel routine, narrowing of stools, cramping, bloody stool, and diarrhea or constipation (Stoppler, 2018).
- Ulcerative colitis – Ulcerative colitis exist when the colon, rectum, or both areas become inflamed, then little ulcers are formed on the lining of the colon. The swelling creates little ulcers on the colon. Symptoms include abdominal pain, bloody stools, diarrhea, fever and rectal pain (Rogers, 2017).
- Food poisoning is caused by consuming food contaminated with toxins such as bacteria, virus, parasite, and prion. Symptoms include abdominal cramping/pain, diarrhea, or vomiting (Wedro, 2018).
Diagnostic testing for the diagnosis listed above include stool occult test, colonoscopy, liver function test, CT scan, or a biopsy. Stool occult test would be used to determine a GI bleed. Liver function test measures the albumin, alanine transaminase, aspartate aminotransferase, alkaline phosphatase, and bilirubin to determine injury or disease of the liver (Biggers, 2017). A CT scan will give a visual of any masses or blockage within the abdomen, and a biopsy will assess tissue for diseases.
Physical examination will include an assessment of the abdomen. It is essential for the inspection to be done first, followed by auscultation, palpation, and then percussion. If the assessment is done in another order, it could interfere with bowel sounds and cause false data. Inspection includes observation of the abdominal area with focus on the abdomen’s shape, abnormalities noted to the skin, masses, and abdominal wall movement with respiration. Abnormalities noted with inspection will require further assessment with auscultation and palpation. Auscultation is used to find negative bowel sounds, bruits sounds, and rubs. Palpation is used to determine crepitus of the stomach, abnormal tenderness, or masses to the abdomen. Percussion is necessary to assess the condition or underline structures of the abdomen (Ferguson, n.d.).