Week 6 Assignment 1: Lab Assessment of the Abdomen
This week’s case study: CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
Chief complaint reports hurting stomach, diarrhea and says it is not responding to medication.
The timing and features of abdominal pain must be taken into account in the HPI. Questions to
clarify which side of the stomach pains are missing. The last time he took medication is also
missing, patient complaints of not taking his medications should be subject to treatment, the
reason for each treatment must be identified and why it stopped.
Negative outcomes for identified colon cancer have been a criterion of differential
diagnosis, and should be identified in the assessment column. The healthcare provider identified
2 generations of family history instead of 3 (Ball, Dains, Flynn, Solomon & Stewart, 2019).
In order to match head to toe evaluations, systems are universally identified. This section
does not include the general assessment. The analytical aspect of the SOAP report needs only
positive outcomes and related negative findings.
The doctor must use palpation and a stethoscope for two successful findings. For the
remainder of the test, the negative results require palpation and auscultation reports. The doctor
may have been accused of the father’s inability to have colon cancer. The colorectal test was also
carried out in accordance with the prostate test (Sullivan, 2019).
Is there sufficient S/O Information
The contextual evidence does not lead to Gastritis. Unless empirical evidence suggests
otherwise, gastritis is not the correct treatment. The symptoms presented of a 3-day diarrhea with
fever do not represent Gastritis (Falcon & Hessen, 2019).
Diagnostic Testing for Abdominal Pain
Diagnostics procedures used to avoid life-threatening differentials and the detection of
obstructions; pathogens and malignancy are aimed at preventing life-threatening diseases (Croft,
Deeks, Dunn, Hay & Hemingway, 2015).
CT abdomen w/2 Contrast Patent examination of diverticular aorta and other mesenteric vessels,
abscesses and masses. Rule out abdominal infection. Guaiac Stool-All that is bloated and
inflamed can bleed.
Assessment of upper-lower GI bleeds or colon wall ulcers.
• Colonoscopy – Look at the colon to see what is present or affected by certain items, such as
ischaemia, in the abdomen.
• Carry out X-ray of the abdomen
• Bilirubin / non-conjugated bile, hepatic albumin, ALT AST time and liver function enzymes
Would I accept or reject the diagnosis in the SOAP?
I would categorically reject the case study diagnosis. His symptoms must be sorted out
thoroughly due to the risk factors and family history of JR.
Aorta Abdominal Aneurysm (AAA) – Arteriosclerosis diabetic pains can occur. The umbilicus is
not always intermediate. For all, anatomy is special.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to
physical examination: An inter-professional approach (9 ed.). Retrieved from
Croft, A., Deeks, J., Dunn, K., Hay, A., & Hemingway, H. (2015). The science of clinical
practice: disease diagnosis or patient prognosis? Evidence about “what is likely to
happen” should shape clinical practice. BMC Medicine, 13(20), 1-8. Retrieved from
Falcon, C. R., & Hessen, M. T. (2019). Magill’s Medical Guide: Abdominal Disorders (Online
ed.). Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?
Sullivan*, D. (2019). Guide to Clinical Documentation (3rd ed.). Retrieved from VitalSource