Clinical Diagnosis: A Case Study of Lower Abdominal Pain

Running head: CLININICAL DIAGNOSIS 1
Clinical Diagnosis
Students Name
Institutional Affiliation

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CLINICAL DIAGNOSIS
Introduction
The patient is Ms Diana F, a 27-year-old female, presented for treatment of lower abdominal
pain that is worsening.
History of presenting symptom and illness
Patient reports that the pain started four days ago and has been increasing in intensity
prompting seek for treatment. The pain is located in the lower abdomen and is cramp-like and
does not radiate to any parts of the abdomen. The patient states the pain to be accompanied by
sweating and diarrhoea. The patient reports her pain to be at 7. The patient says that since two
years ago, she has been having abdominal pain occasional times with diarrhoea that sometimes
contains blood. Some of the questions I would ask include; what pattern does the pain take over
24 hours? Does the pain have an effect on daily activities? Can you explain a single pain
episode? How often are your bowel movements? Have you experienced any changes in bowel
movements? How often do you experience bloody diarrhea and how much is it?
Past medical history
The patient has a history of childhood asthma which was effectively controlled. She had
tonsillectomy done at the age of 15 years and reports no complications afterwards. The patient
has no history of any previous GIT problems such as appendicitis, ulcers or gall bladder disease.
No previous abdominal surgeries or any injuries to the abdomen.
Family history

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Mother has a history of suffering from chronic asthma and eczema. There is no history of
GIT problems in the family neither there is chronic abdominal pains or diarrhea. No history of
cigarette smoking or alcohol use.
Social history
She smokes cigarette at least 10 per day and takes alcohol during weekends
approximately 3-5 drinks. Cigarette smoking triggers the relapse if inflammatory conditions such
as asthma and crohns disease.
Medical allergies
Patient reports having an allergy to NSAIDS and no known food allergy. Asthma is
related to development of crohns disease. The patient might be allergic to pollen, cold or fur and
the GIT symptoms may exacerbate during exposure to this allergens.
Systems Review to ensure that there are not any other conditions or complications.
GIT system.
I will ask on the feeding patterns of the patient and ask the time the last meal was
ingested. The rationale is because normally after meals, there is an increase in bowel sounds.
Approximately 5 hours after a meal, the bowel sounds are heard rapidly on the right lower
quadrant during emptying into the large intestine. I will ask about the duration of the diarrhea.
An acute diarrhea originates from an infection like fecal oral transmission and lasts to a
maximum of two weeks. Chronic diarrhea lasts more than four weeks and it is normally
associated with crohns disease or ulcerative colitis (Aganzo, Luiza, Herrero, &Vazquez, 2018). I
will ask on the amount of diarrhea, the frequency and viscosity. Watery frequent stools that

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occur in large amounts originate from the small intestine. Mucoid, pus or blood-stained stools
originate from inflammatory cases of colon and rectum.
Respiratory system
I will assess for any symptoms of asthma exacerbation or occurrence of pneumonia as a
complication. Chest pain experienced in pneumonia can be referred to the abdomen and mislead
the diagnosis.
Integumentary system
The patient has a history of eczema in the family. I will ask the patient on the age of onset
of eczema on the mother and assess for any symptoms. I will perform immune tests since eczema
is an autoimmune disease.
Genitourinary system
I will ask on the frequency, of urination and any changes of the past days. Urinary
infection can lead to conditions such as appendicitis or diverticulum that can present as lower
abdominal pain (Ciccone et al., 2015). I will ask on the last menstrual period and perform a
pregnancy test since case of ruptured ectopic can present with lower abdominal pain.
Musculoskeletal system
I will ask on evidence of joint swelling. Patient with Crohn’s disease present with
inflammation of joints. Performing range of motion on joints and palpating them can reveal areas
of swelling (Mahmood, Shabbir, Chistol, I., & Khan, 2019).