Case study Week 6- Assessment of the Abdomen and Gastrointestinal System

There will also be current literature and analytical tests that will be evaluated as part of the important information from the patient where various determinations are going to be discussed and data which support or reject each assessment.Analysis of the Subjective DataBased on the subjective data of the patient, it can be revealed that the patient’s history with the present illness is not clear and there is a need to look for more data. The clinicians must look for the ineffectiveness of limited, dull, or aching pain that is developed due to instinctively innervated organs that are contrasted to the distinctively 'sharp'.  It is also evident from the subjective data that the patient is experiencing generalized pain, however, he does not know the trigger (Natesan et al., 2016).  Among the common components is the reaction to eating. Also, it is important to look at evidence of any emesis which the patient could be having and information regarding the solid bowel movement or if there are traces of stool in the blood.  Any trace of it could help reveal if the patient is suffering from the gastrointestinal tract.  It is also important to look at the patient's diet and when he last ate, this can be done through conducting a 24-hour review of his diet and whether he introduced anything strange in his meal as this could have aggravated the gastrointestinal tract.  It is also important to know whether he might have travelled to another region as this would result in protozoal contamination (Miller & Alpert, 2006). Also, the patient's past medical history was very important as it showed that he experienced a bleed four years ago. It would also be important to find out whether he was hospitalized in the process and whether the reason for hospitalization as gastrointestinal bleed.  Also whether he was performed a surgical procedure like colonoscopy or GI.Analysis of Objective DataObjective data includes reviewing the patient vital signs which could reveal the potential shock and provide information regarding the current patient's clinical status.  From the subjective data, it is evident that the patient's temperature is low grade, and his blood pressure is hoisted which could be caused by the blood pressure regimen resistance.  It would also be important to look at the skin color, capillary refill, and mucous membrane including the patient's eyes to assess if he is also dehydrated.  It would also help if the abdominal assessment looked at both quadrants, especially if the left lower quadrant show signs of organomegaly on palpation (Madgaonkar, 2011). It is also important to look at whether the area in the patient's stomach was rounded or flat, also one should look at other regions with discoloration, also due to the size of the patient it is possible that the stomach area is going to be standard.  Distention also means fluid, gas, or ascites presence, especially if it happens to relate to the averted umbilicus.  The auscultation also looks at the constrained symptomatic utility, where if prolonged could lead to bowel sounds which leads to ineffective use of time and the one experienced with abdominal fiasco or ileus.3. Whether the assessment is supported with subjective or Objective InformationThe assessment reveals a left lower quadrant discomfort and gastroenteritis. In this way, it can be said that the assessment is supported with objective information which shows the left lower quadrant torment from derived from the physical examination and the various conclusion on gastroenteritis (Madgaonkar, 2011). However when it comes to the subjective data, it can be concluded there are no essential areas related to the SOAP note (Avegno & Carlisle, 2016).  The need to include lab tests, diagnostics, current co-morbidities, differential determination to come up with complete analysis. It is also important to clarify assessment information which is required in the incorporation of all the essential body areas to provide objective or subjective proof.Appropriate Diagnostic TestsBased on the SOAP note, the diagnostic tests should also include a Complete Blood Count, Basic Metabolic Panel, Stool culture, CT exam, and X-ray.    The complete Blood count test is appropriate because the patient reports a past with a gastrointestinal bleed, this will be important to determine whether the patient is likely to experience   GI bleed again and provide a suitable treatment plan (Madgaonkar, 2011).  Also conducting a Basic Metabolic Panel test can help in the provision of an exact picture of the electrolyte status of the patient.  Based on the fact that the patient is diabetic, it means that his renal capacity matters a lot, the blood urea nitrogen, and the level of sugar which can lead to dehydration.  Because the patient has also had abnormal bowel, this could lead to liquid exhaustion lea