Soap Note Analysis Of Epigastric Abdominal Pain Assignment

Soap Note Analysis Of Epigastric Abdominal Pain Assignment

Assignment:

ABDOMINAL ASSESSMENT

Subjective:

CC: “My stomach has been hurting for the past two days.”

HPI: LZ, 65 y/o AA male, presents to the emergency department with a two days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s with no relief. At this time, the patient reports that the pain has been increasing in severity over the past few hours; he vomited after lunch, which led his to go to the ED at this time. He has not experienced fever, diarrhea, or other symptoms associated with his abdominal pain. Soap Note Analysis Of Epigastric Abdominal Pain Assignment

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PMH: HTN

Medications: Metoprolol 50mg

Allergies: NKDA

FH: HTN, Gerd, Hyperlipidemia

Social Hx: ETOH, smoking for 20 years but quit both 2 years ago, divorced for 5 years, 3 children, 2 males, 1 female

Objective:

VS: Temp 98.2; BP 91/60; RR 16; P 76; HT 6’10”; WT 262lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: abdomen is tender in the epigastric area with guarding but without mass or rebound.
Diagnostics: US and CTA
Assessment:

Abdominal Aortic Aneurysm (AAA)
Perforated Ulcer
Pancreatitis
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

With regard to the Episodic note case study provided:
Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study. Soap Note Analysis Of Epigastric Abdominal Pain Assignment
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Analyze the objective portion of the note. List additional information that should be included in the documentation.
Is the assessment supported by the subjective and objective information? Why or why not?
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

Subjective Portion Analysis

The HPI provided helpful insight into the nature of the pain, identifying it as epigastric abdominal pain with back radiation that occurs intermittently. Other manifestations of the pain, such as its growing intensity over the course of the last several hours, are also mentioned. The HPI, on the other hand, was unable to pinpoint the specific region of the back where the pain was traveling to. Additionally, it did not mention the level of pain that was being experienced. Subjective data should also contain the severity of pain when it began, what caused it, what events may have triggered it, as well as any relevant trauma or surgical histories. Likewise critical is information on the time and quantity of the last alcoholic beverage consumed. Furthermore, the subjective data lacked the Review of Systems. Important gastrointestinal details include the time and nature of the patient’s most recent bowel movement, as well as any associated changes in bowel routine. Reports of chest discomfort, palpitations, or shortness of breath are all important pieces of information to collect under the cardiovascular system. Soap Note Analysis Of Epigastric Abdominal Pain Assignment

Objective Portion Analysis

Regarding the stated epigastric pain, the objective section provided an insufficient amount of details. To assist in arriving at the most accurate diagnosis possible, it is important to record not only a comprehensive evaluation of the gastrointestinal system but also the functioning of other linked systems, like the vascular and cardiovascular systems. The objective portion also needed to incorporate the findings of the ultrasound and the computed tomography angiography. If the client’s laboratory tests, physical examination, and medical history all come up negative while trying to determine the source of their pain, diagnostic imaging may be necessary (Marasco et al., 2019).

Diagnostics

Imaging studies such as X-rays, ultrasonography, or endoscopy are essential components of the diagnostic process for epigastric abdominal pain (Marasco et al., 2019).In addition, an electrocardiogram is essential in order to exclude the possibility of a cardiac event. Cardiac assays, including cardiac troponins, may also be employed to exclude pericarditis and heart attack as possible causes of the patient’s symptoms (Anand et al., 2020)Soap Note Analysis Of Epigastric Abdominal Pain Assignment.

Is the Assessment Supported by Subjective & Objective data?

The diagnosis of an abdominal aortic aneurysm is backed up by the client’s subjective information, which includes the presence of abdominal pain and a history of tobacco consumption. The diagnosis of pancreatitis is solely substantiated by the subjective information related to epigastric discomfort; the objective information does not back this assessment. The objective and subjective data given are rather consistent with a diagnosis of a perforated ulcer due to the patient’s history of cigarette smoking, consumption of alcohol, hypotension, and abdominal discomfort.

Differential Diagnosis

Ulcerative colitis, mesenteric ischemia, and acute gastritis are all plausible illnesses that might explain this patient’s symptoms. Pain in the upper abdomen (epigastric) is a symptom of mesenteric ischemia, which is caused by the inadequate blood supply to the mesenteric artery. Pain in the upper abdomen and an absence of rebound tenderness characterize acute gastritis. Ulcerative colitis is a chronic illness that leads to ulcerations inside the large bowel. These ulcerations may be painful and debilitating. More than half of those who have ulcerative colitis report experiencing persistent abdominal discomfort as one of their symptoms. Soap Note Analysis Of Epigastric Abdominal Pain Assignment

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References

Anand, A., Lee, K. K., Chapman, A. R., Ferry, A. V., Adamson, P. D., Strachan, F. E., Berry, C., Findlay, I., Cruikshank, A., Reid, A., Collinson, P. O., Apple, F. S., McAllister, D. A., Maguire, D., Fox, K. A., Newby, D. E., Tuck, C., Harkess, R., Keerie, C., … Mills, N. L. (2020). High-sensitivity cardiac troponin on presentation to rule out myocardial infarction: A stepped-wedge cluster randomised controlled trial. https://doi.org/10.1101/2020.09.06.20189308

Marasco, G., Verardi, F. M., Eusebi, L. H., Guarino, S., Romiti, A., Vestito, A., Bazzoli, F., Cavazza, M., & Zagari, R. M. (2019). Diagnostic imaging for acute abdominal pain in an emergency department in Italy. Internal and Emergency Medicine, 14(7), 1147-1153. https://doi.org/10.1007/s11739-019-02189-y Soap Note Analysis Of Epigastric Abdominal Pain Assignment