Posted: October 24th, 2022

Differential Diagnosis

Differential Diagnosis

This task goals at distinguishing a wide range of medical circumstances which seem like related by way of indicators and signs, on a 47-year-old affected person complaining of extended belly discomfort. The paper will analyze each the subjective and goal parts of the SOAP notes and as effectively present the prognosis exams which can be most acceptable in figuring out the affected person’s prognosis.
Subjective Assessment
The affected person is 47 years previous whose chief criticism is abdomen pains, the onset of diarrhea which has been happening for three days. The affected person seems effectively nourished, that’s, he seems to be wholesome and robust bodily. He has not been beneath any treatment for the reason that pains began however has subsided from its severity when it began, from 9/10 to a 5/10 ratio. In keeping with his medical historical past, there are recorded circumstances of Hypertension, Diabetes and Gastrointestinal bleeding courting again to 4 years in the past. The affected person has no file of allergic response to any drug that has been administered to him up to now.
As required throughout a medical prognosis, the doctor has to try the household historical past of the affected person. When the well being historical past of the household was examined, there was absence of circumstances of colon most cancers which may have been one of many potential causes for the belly pains. The absence of colon most cancers within the household historical past nonetheless doesn’t rule out the potential for its prognosis on the affected person, it solely lowers the chance of its risk since most cancers might be hereditary. The information additionally confirmed that the affected person’s father had a historical past of Diabetes Kind 2. In medication, it is a threat issue for the affected person and subsequently Diabetes Kind 2 was documented as one of many sicknesses to be examined within the affected person. Each the mom and the daddy to the affected person additionally had a historical past of Hypertension which additionally may very well be among the many threat components through the prognosis of the affected person. The mom had a historical past of Hyperlipidemia and GERD which had been each recorded for additional examination on the affected person. The social lifetime of the affected person was thought-about wholesome since there was no file of tobacco, nonetheless there was occasional ingesting which may trigger different well being issues that would have an effect on the stomach. The affected person has three youngsters and spouse which might immediate the doctor to make an Assessment of the household relations inside his family which might elevate the chance of his sickness reminiscent of stress ranges. The household monetary standing ought to subsequently be examined to be able to improve the prognosis since monetary constrain with a big household like that of the affected person may result in stress. The marital stability standing must also be examined to find out its contribution to the affected person’s well being standing.
Goal Assessment
After an examination by the doctor, the affected person’s important indicators had been as follows; the temperature was at 99.80 F. The traditional temperature of the human physique ranges between 97.80 F-990 F which signifies that the affected person’s physique temperature was inside vary. His blood stress was at 160/86 whereas the conventional blood stress needs to be at 120/80. The affected person exceeded the conventional blood stress, his systolic was at stage 2, it was increased than 140 which is a warning signal and the diastolic was at stage 1 falling between 80-89. This was an alarming signal which was recorded as a threat issue for a number of sicknesses particularly these associated with stress. His respiration charge was inside vary falling between the 12-16 vary, at 16 breaths per minute. His pulse charge which represents each the energy of the heartbeat and the center rhythm was at 92beats per minute which was inside the regular 60-100. His Physique mass index was approach above regular at 36.9 and the affected person was thought-about overweight, weight problems is asserted at BMI higher than 29.9. Different exams on the center charge we regular, his lungs had been useful and his pores and skin was in good situation with no abnormalities detected. When his stomach was examined, softness, hyperactivity within the bowel accompanied by sounds, and pos ache in his left decrease quadrant was recorded. The doctor ought to have examined his Physique Mass Index which, with the given peak and weight, was approach above regular at 36.9 and the affected person was alarmingly overweight, weight problems is asserted at BMI higher than 29.9.
Nature of the Assessment
The medical Assessment was supported extra by the target data since these had been the verifiable info through the affected person’s prognosis. Within the subjective Assessment, the affected person appeared effectively nourished, and denying consumption of tobacco and occasional consumption of alcohol had been topic to bias. It’s only by way of the target Assessment that hypertension and weight problems had been detected which created room for extra knowledgeable prognosis.
Diagnostic exams
In addition to taking the affected person’s well being historical past, bodily examination could be very important which would come with exams reminiscent of palpation. Palpation would require the doctor to softly exert stress on numerous components of the stomach to evaluate tenderness and ache. The presence of ache on a sure half just like the left decrease quadrant would Help the doctor make a wide range of prognosis associated to the digestive tract, belly wall muscle mass, blood vessels and the affected person’s reproductive organs. A lab check is also performed the place an Occult Stool could be used to test for blood within the stool. The affected person had complained of diarrhea which might make the check acceptable in checking for indicators of an infection within the abdomen. CT scan on the decrease stomach could be very important within the prognosis as they’re extra exact on the place the sickness may very well be (Mendelson, 2015).

Potential differential prognosis
One of many potential differential prognosis is the presence of Crohn illness characterised by belly ache with bloody diarrhea. The affected person is also affected by Ureterolithiasis which is characterised by colicky ache which can be progressive then turning to fixed. The affected person reported the ache to have been extreme at first then lowered with time, which may very well be brought on by the physique tolerating to the ache. The opposite symptom of ureterolithiasis is ache within the decrease stomach which was detected within the affected person’s decrease left quadrant (Dains et al., 2015).
The opposite potential situation may have been Incarcerated hernia which is characterised by extreme ache in both the RLQ or the LLQ as detected within the affected person. Weight problems might consequence to intestinal obstruction the place the intestines are blocked and will consequence to the belly pains skilled by the affected person in addition to diarrhea (Sharma et al, 2017). The fats is causes the blocking on blood vessels and will result in hypertension which is frequent amongst overweight folks. The affected person exceeded the conventional blood stress, his systolic was at stage 2, it was increased than 140 which is a warning signal for hypertension (Afolabi, & Guo, 2014).

References
Afolabi, J., & Guo, H. (2014). Guiding Hypertensive Grownup Sufferers: A Literature Assessment of Proof-Based mostly Nursing.
Dains. E. J., Baumann L.C., & Scheibel P., (2015). Superior Well being Assessment and Scientific Diagnosis in Main Care. fifth Version. ELSEVIER, 30(5), 236-237.
Mendelson, R. (2015). Diagnostic exams: Imaging for continual belly ache in adults. Australian prescriber, 38(2), 49.
Sharma, L., Srivastava, H., Pipal, D. Okay., Kothari, S., Dhawan, R., & Purohit, P. M. (2017). Acute intestinal obstruction: small gut vs. massive gut: an Assessment. Worldwide Surgical procedure Journal, 5(1), 162-167.
Yang, X. F., & Liu, J. L. (2014). Acute incarcerated exterior belly hernia. Annals of translational medication, 2(11).

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