Additional Information that should be Included in the Documentation of Subjective Data
Subjective data is the information that is given to a healthcare provider from the point of view of a patient. Therefore, it includes the concerns, feelings, and perceptions that are obtained through interviews. In the scenario given, the chief complaint of the patient was that of generalized abdominal pain. Apart from asking about the intensity of the pain on a scale of 0-10, it is important to include information on the quality of the pain, whether or not it is migratory or localized, increase or decrease in severity, where it originates from and radiates to. Besides, it should be included whether the pain was of sudden or gradual onset. The patient should also be asked to explain what she was doing when the pain started. The importance of determining any aggravating or relieving factors for the pain cannot be underestimated. As supported by Oberstein & Olive (2013), this information is essential in narrowing down to some of the most probable diagnoses.
Although the patient reported about diarrhea, additional information on bowel and urinary habits should be included. This includes the duration and an approximate number of episodes of diarrhea in a day, relieving and aggravating factors, other associated symptoms for diarrhea. Information on the urinary habits such as urine incontinence, hesitancy, dysuria, urgency, and increased frequency should also be included. Still on bowel and urinary habits, information on odor, color, and discomfort after or during a bowel movement should be included. Patients with pancreatic cancer often experience darkening of urine and stool lightening (Vincent, Herman & Goggins, 2011). Potential associated symptoms of abdominal pain such as vomiting and nausea should be established.
It is clear that the patient had a history of GI bleeding 4 years ago. Therefore, information on the absence or presence of blood in vomitus or stool should be included noting the color and smell. Since she is hypertensive and diabetic on medications, information on medication adherence should be included. It is also mandatory to include information on the occupation of the patient as this would help to determine possibilities of abdominal injury.
Additional Information that Should Be Included in the Documentation of Objective Data
Following the chief complaint of generalized abdominal pain, this patient needed a detailed physical and abdominal examination. Therefore information on the patient’s general appearance should be included which may be; sick-looking, in severe pain, lethargic, noting the patient’s mental status, gait, and nutritional status. Patients with pancreatic cancer are often cachectic and malnourished. Information on jaundice, pallor and skin pigmentation should be included. Anemia, jaundice and skin excoriation are characteristic findings in patients with pancreatic cancer (Halbrook & Lyssiotis, 2017). Jaundice may be associated with a non-tender, distended palpable gallbladder that is elicited using the Courvoisier sign, skin excoriation due to pruritus, acholic stool, and darkening of the urine.
Additional information would include may be obtained from inspection, percussion, palpation, and auscultation of the abdomen. On inspection, information on abdominal distension is necessary. In patients with pancreatic cancer, abdominal distension often acutely which is more painful. Information on the presence or absence of scars is also necessary. The presence of scars on the abdomen is an indicator for previous surgeries which would add on already available information to get a more accurate diagnosis (Ryan, Hong & Bardeesy, 2014). Besides, information on the presence or absence of visible distended veins on inspection should be included.
On palpation, information on whether the abdomen is soft, rigid, fluid-filled, tender, non-tender guarding or with rebound tenderness should be included. In guarding, patients tighten the muscles of the abdomen. Rigidity is highly suggestive of digestive juices, blood or bowel substances in the peritoneal cavity. Masses are suggestive of an aneurysm, tumors or a bowel that is obstructed. In patients with pancreatic cancer, characteristic findings include: a palpable intra-abdominal mass, peri-umbilical mass called Sister Mary Joseph node, ascites and non-tender palpable gallbladder (Oberstein & Olive, 2013). Information on the abdominal areas where there is increased tenderness on palpation is necessary in narrowing down to specific causes that relate to the clients clinical presentation that would guide the diagnostic, laboratory or radiological imaging studies to be conducted for the patient.
Whether the Assessment Is Supported by the Subjective and Objective Information
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