Question

  Module 04 Lab Assignment – Documentation of an Assessment of the Gastrointestinal System

You will perform a history of an abdominal problem that your instructor has provided you or one that you have experienced and perform an assessment of the gastrointestinal system. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the dropbox provided.

Remember to be objective when you document; do not make judgments. For example, if the person has a palpably enlarged liver, do not write “the liver is enlarged probably because they drink too much.” Avoid stating that something is normal but instead state WHY you think it is normal. For example, if you think that the abdomen looks “normal” - which is subjective - then document that the “abdomen is flat, skin color consistent with rest of body, no lesions, scars, bulges, or pulsations noted.”

Subject: physical assessment. please write separate objective, subjective and potential risks. Thanks a lot.

Answer 1

Assessment of the Gastrointestinal system of a patient with  Appendicitis:

Appendicitis: Inflammation of the Vermiform apendix.

Gastrointestinal Assessment/ Abdominal examination: It is an important part of Physical examination.

Subjective data: (Health history questions )

Appetite: loss of appetite from 3 days

Usual weight: weight loss of 1 kg in 2 week

Swallowing : No difficulty in swallowing

- Nausea and vomiting from 3 days

- Complaints of peri umblical pain and diarrhoea

Past abdominal history:

No past history of ulcer, hepatitis, jaundice, colitis and hernia

No surgical history of abdomen

Abdominal examination:

* Inspection

Skin: surface normally smooth, no colour changes when comparing with  remaining body parts

Symmetry : No asymmetry, bulging or masses

Abdominal contour: flat

Umblicus on Central line

No scars or injuries or swelling

* Palpation

- Pain at the McBurney point

- Rebound tenderness

- Right lower quadrant ( RLQ) tenderness

- Rovsing sign is present ( RLQ pain, on palpation of Left lower quadrant)

No spleenomegaly or hepatomegaly

* Percussion

- Pain on percussion

- No fluid or gas collection

* Auscultation:

Bowel sounds: Decreased bowel sounds

C.T scan : Increased diameter of Appendix > 6mm.

Potential Risks: Potential risks of Appendicitis are bowel obstruction, pelvic or abdominal abscess , wound infection, dehiscence .

( No options for medical problem was not provided in the question. So i selected a medical problem ( Appendicitis) of my choice . If any preference, you can comment. Thank you.)