SOAP Notes For Abdominal Pain Ass
SOAP Notes For Abdominal Pain Assignment
Bio Data
Patients Initials: G.G
DOB: 12/2/1954
Age: 68
Gender: male
Race: African American
Subjective Data
Chief Complaint: abdominal pain
History of presenting Illness: Mr.GG, 68 years old African American male is accompanied by his wife and daughter and presented with abdominal pain for the last one month. He reports that it is mainly in the epigastric region dull in nature, on-radiating, aggravated on ingestion of NSAIDs and spicy food. He reports that the pain has no specific timing and rates the pain as a 5/10. He states that it is associated with nausea, acid reflux and bloating. The pain is not relieved by taking analgesics. SOAP Notes For Abdominal Pain Assignment
ORDER A PLAGIARISM-FREE PAPER HERE
Current medications
OTC paracetamol 1g 8 hourly for abdominal pain
Hydrochlorothiazide 25mg 24 hourly for hypertension.
Allergies
No known food or drug allergy.
Past medical history
He is a known hypertensive patient for 3 years now.
Past surgical history
Positive history of hemoroidectomy 10 years ago.
Health maintenance
His last physical was 6 months ago and was within normal. He takes a walk three times a week and takes a balanced diet.
Immunization
His vaccination is up to date. His last vaccine was AstraZeneca covid 19 vaccine.
Family history
He is the 3rd born in a family of 3. All siblings are alive and well. His brother is diabetic.
Mother and father died 15 years ago secondary to a road traffic accident.
Maternal grandmother is alive and hypertensive.
Maternal grandfather is deceased secondary to a cerebrovascular accident.
Paternal grandfather is deceased due to old age.
Paternal grandmother is deceased due to unknown illness.
Social history
He is married and has 5 living children. Has a positive history of cigarette smoking and alcohol consumption but stopped 3 years ago. He denies illicit substance use.He is a retired teacher. SOAP Notes For Abdominal Pain Assignment
Allergy
No history of hay fever, asthma or eczema.
ROS
General: denies history of chills, fever or chills.
CNS: denies headache, convulsion or loss of consciousness.
HEENT: denies blurry vision, ear pain or discharge, nasal drainage or difficulty in swallowing,
Respiratory: denies cough, wheezing or difficulty in breathing.
Cardiovascular: positive history of retrosternal chest pain, denies shortness of breath, or palpitations.
GIT: positive history abdominal pain, denies nausea and vomiting.
Genitourinary: denies hematuria, increased urinary frequency and dysuria.
Musculoskeletal: denies joint pain, swelling or stiffness.
Psychiatry: denies visual or auditory hallucination and suicide ideations. SOAP Notes For Abdominal Pain Assignment
Objective Data
General: Mr.GG 68 year old African American male is in a fair general condition.
Vital signs: BP 128/80mm/hg, PR 68beats/minute, temperature 37.2 degrees Celsius, RR 16 breaths/minute, spo2 98% room air, BMI 26kg/m2.
HEENT: the head is normocephalic, no masses or lesions. Eyes: no eye discharge or periorbital edema. Ear: no ear pain or discharge, hearing is intact bilaterally. Nose/mouth/throat: septum is centrally located; membranes are moist, pink and intact. There is evidence of dental erosions.
CNS: alert, oriented in time, place and person. Cranial nerves are grossly intact bilaterally.
Cardiovascular: normoactive precordium. s1 and s2 heard with no heaves or thrills.
Respiratory: the chest wall is symmetrical. Normal rhythmic breathing and there is equal and bilateral air entry.
Gastrointestinal: the abdomen is soft and moving with respiration. No scars or obvious swelling is noted. Tenderness on the epigastric region on palpation. However, no guarding or rebound tenderness noted. Bowel sounds are heard and present.
Genital/rectal: patient declined.
Musculoskeletal: no joint pain or stiffness. Normal gait and posture.no congenital anomalies or limb deformities.
Diagnostic tests
- Pylori stool antigen: rule out h-pylori infection.
Assessment
Primary Diagnosis
GERD: a condition that causes involuntary reflux of gastric contents into the esophagus. Risk factors associated with GERD include; obesity, tobacco use, increased intra-abdominal pressure, NSAID or aspirin and advance age >50 years (Kellerman & Kintanar, 2017). The clinical manifestation comprises; regurgitation, epigastric pain, dysphagia, nausea and heartburn.
Differential diagnosis
H.pylori infection: an infectious disease that is caused by H.pylori, a gram-negative spiral shaped bacterium which is transmitted via fecal oral, sexual, oral-oral and gastric-oral route (Parikh & Rajni Ahlawat, 2021)SOAP Notes For Abdominal Pain Assignment. The clinical manifestation consist; dyspepsia, nausea, vomiting or abdominal pain.
Peptic ulcer disease: an acid-induced lesion that leads to discontinuation in the inner lining of the GIT which extends to muscularis propria layer of the gastric epithelium. The classical presentation includes; epigastric pain which starts within 15-30 minutes after a meal with a gastric ulcer or 2-3 hours in cases of duodenal ulcer (Malik et al., 2021). Other symptoms are; nausea, vomiting, hematemesis, bloating, and others. The main causes include; H.pylori and excessive use of NSAIDs.
Acute Gastritis: inflammation of the stomach wall lining which is mostly caused H.pylori steroids/NSAIDs, autoimmune gastritis, H.pylori, tobacco smoking and excessive alcohol consumption (Azer & Hossein Akhondi, 2022)SOAP Notes For Abdominal Pain Assignment. Patients present with symptoms of nausea, sudden onset of epigastric pain and vomiting.
Plan
Pharmacotherapy
- PO Esomeprazole 20mg 12 hourly.
Education
- Lifestyle modifications; advice patient to avoid use of spicy food, chocolate, caffeine and NSAIDs.
- Encourage the patient to avoid meals at least 3 hours before bedtime.
ORDER TODAY
Reference
Azer, S. A., & Hossein Akhondi. (2022,). Gastritis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544250/
Kellerman, R., & Kintanar, T. (2017). Gastroesophageal Reflux Disease. Primary Care: Clinics in Office Practice, 44(4), 561–573. https://doi.org/10.1016/j.pop.2017.07.001
Malik, T. F., Karthik Gnanapandithan, & Singh, K. (2021, ). Peptic Ulcer Disease. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534792/
Parikh, N. S., & Rajni Ahlawat. (2021,). Helicobacter Pylori. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534233/ SOAP Notes For Abdominal Pain Assignment