Review the Episodic note case study your instructor provides you for this week’s Assignment. Please see the “Course Announcements” section of the classroom for your Episodic note case study.

Walden University| NURS 6512 – Advanced Health Assessment and Diagnostic Reasoning | Walden University

  1. Additional information should be added to the documentation in the subjective section of the note:
  • Description of your abdominal pain: location, type and intensity; duration; frequency; aggravating factors.
  • Additional gastrointestinal symptoms: Vomiting, gas, constipation and blood in the stool
  • Recent changes in diet or lifestyle
  • Recent travel and exposure to infectious disease
  • A family history of gastrointestinal problems
  1. The objective part of the note should contain additional information.
  • Other quadrants of abdominal examination results
  • Rectal examination results (if performed)
  • Any other diagnostic tests (if any) performed
  1. As the patient has abdominal pain and hyperactive bowel sounds (LLQ), the objective and subjective information support the diagnosis of gastroenteritis. Additional investigations are possible to rule other conditions.
  2. This case may require the following diagnostic tests:
  • Infectious gastroenteritis: Stool culture and sensitive testing to determine the cause
  • For electrolyte and dehydration concerns, please complete the blood count.
  • A CT scan or Abdominal Ultrasound to assess for structural abnormalities and inflammation in the gastrointestinal tract

This can be used to help diagnose and decide the best treatment option.

  1. The current diagnosis may be correct based on limited information in this case study. Other conditions may also present similar symptoms, and these should be taken into consideration in the differential diagnosis.
  • Inflammatory bowel disease (such as Crohn’s disease or ulcerative colitis)
  • Irritable bowel syndrome
  • Diverticulitis

You can differentiate between these conditions by taking additional notes, performing a physical exam and using diagnostic tests. Inflammatory bowel disease can present as persistent diarrhea, weight loss and rectal bleeding. Diverticulitis, on the other hand, may be characterized by fever, abdominal tenderness, and chills.

References:

  1. Crohn’s & Colitis Foundation. (2022). Symptoms of Crohn’s Disease. https://www.crohnscolitisfoundation.org/what-is-crohns-disease/symptoms
  2. American College of Gastroenterology. (2021). Syndromes of the Irritable Bowel. https://gi.org/topics/irritable-bowel-syndrome/
  3. American Society of Colon and Rectal Surgeons. (2019). Diverticulitis. https://www.fascrs.org/patients/disease-condition/diverticulitis-disease-0

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