Assessment: Assessing the Abdomen

The SOAP note concerns a 65-year-old AA man who comes to the ED with a two-day intermittent epigastric abdominal pain radiating to the back. He has a medical history of HTN. Examination of the abdomen reveals abdominal tenderness in the epigastric area and guarding but no abdominal mass or rebound. The identified assessment findings are Abdominal Aortic Aneurysm (AAA), Perforated Ulcer, and Pancreatitis. The aim of this assignment is to analyze the SOAP note and identify possible diagnoses.

ORDER A CUSTOMIZED, PLAGIARISM-FREE PAPER HERE

Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us

Subjective Portion

The HPI should have included the timing of the abdominal pain, for example, if it comes before or after having meals. It should also have information describing the abdominal pain, like sharp, dull, colicky, or aching (Vaghef-Davari et al., 2019). Information should be provided describing the vomiting episode, including the amount and characteristics of the vomitus. Furthermore, the HPI should have the non-pharmacological relief measures the patient has implemented for abdominal pain. The name, dose, and frequency of the PPI should have been given. The PPI should also have the pain’s triggering and relieving factors. Since the patient has GI symptoms, the HPI should include information on his bowel patterns and if he has blood in his stool (Vaghef-Davari et al., 2019). In addition, the HPI should have the patient’s dietary information, average daily fluid intake, recent travel, and exposure to illness. The HPI should also include the severity of the abdominal pain.

The past medical history should include dates at which the HTN was diagnosed and if it is controlled or uncontrolled. The frequency of Metoprolol should also be provided, and if the patient is compliant with the medication. In addition, the subjective portion should have the patient’s immunization history with dates of the last shots and surgical history with dates of each surgical procedure. The family medical history should include the family members with HTN, GERD, and Hyperlipidemia and whether they are alive. Furthermore, the social history should have included information on the type, amount, and frequency of alcohol intake and the number of cigarettes the patient smoked. It should also include the patient’s current living situation, financial situation, and health insurance status. The HPI should also have a Review of Systems (ROS) with pertinent positives and negatives for each body system.

Objective Portion

The vital signs should include the patient’s BMI to determine if he is underweight, normal, or overweight/obese. It should also include findings from the general assessment, including the client’s grooming, degree of distress, alertness, orientation, eye contact, and facial expressions. The abdominal exam should have comprehensive findings from inspection, auscultation, percussion, and palpation. The inspection findings should include pigmentation, symmetry, contour, respiratory movement, and scars. Auscultation findings should include bowel sounds, venous hum, and vascular sounds. Findings from the general percussion of the spleen, stomach, and liver span and fist percussion of the kidney, liver, and bladder should be present (Yamashita et al., 2020). Furthermore, findings from light and deep palpation of the abdomen should be provided, including the presence of organ enlargement, bulges, and swelling are vital.

Assessment

AAA is supported by subjective information about abdominal pain, which occurs in enlarging aneurysms. Palpation of the abdomen in AAA usually reveals a non-tender, pulsatile abdominal mass. The objective finding of abdominal tenderness without masses does not support AAA. Perforated ulcer present with sudden and severe epigastric pain and thus is supported by subjective information about epigastric abdominal pain (Manu et al., 2021). Pancreatitis is supported by subjective information of epigastric abdominal pain radiating to the back and vomiting and objective findings of abdominal tenderness and guarding.

Diagnostic Tests

The appropriate diagnostic tests for this case will include a complete blood count (CBC), abdominal ultrasound, and fecal occult blood test (FOBT). The CBC will help to identify if the patient has an underlying inflammation or infection and rule out low RBC usually due to anemia (Vaghef-Davari et al., 2019). An abdominal ultrasound will also help establish the cause of the abdominal pain. FOBT will check stool samples for occult blood, usually caused by peptic ulcers, gastritis, and inflammatory bowel disease.

Diagnosis

Abdominal pain in AAA occurs during a rupture and is usually diffuse, severe pain with abdominal distension, and the patient usually gets into shock (Sakalihasan et al., 2018). AAA is not supported by adequate subjective and objective information and would thus reject it as a primary diagnosis.

Acute Pancreatitis: Pancreatitis usually presents with abdominal pain in the epigastric region that radiates to the back, often associated with nausea and vomiting. Abdominal exam in Pancreatitis reveals abdominal tenderness, guarding, and decreased bowel sounds (Ashraf et al., 2021). Thus, Pancreatitis is a differential diagnosis based on positive findings of epigastric abdominal pain radiating to the back, vomiting, abdominal tenderness, and guarding,

Peptic ulcer disease (PUD): The clinical manifestations of PUD include epigastric tenderness, nausea, vomiting, dyspepsia, and a rigid board-like abdomen with rebound tenderness and pain if there is perforation into the peritoneal cavity (Manu et al., 2021). PUD is a differential owing to positive symptoms of epigastric tenderness, vomiting, and abdominal tenderness.

Acute Cholecystitis: The classic presentation of Acute cholecystitis includes acute RUQ pain, fever, nausea and vomiting associated with meals, and RUQ tenderness (Gallaher & Charles, 2022). Upper abdominal pain and vomiting support Acute cholecystitis as a differential diagnosis.

Conclusion

The subjective portion should have more information on the abdominal pain, including characteristics, timing, aggravating/relieving factors, and severity. The characteristics and amount of vomitus and bowel patterns should be included. The objective findings should have included the BMI, general assessment, and comprehensive abdominal exam findings. Appropriate diagnostic tests for this case include CBC, abdominal ultrasound, and fecal occult blood test. The possible conditions are Acute Pancreatitis, PUD, and Acute Cholecystitis.

ORDER A CUSTOMIZED, PLAGIARISM-FREE PAPER HERE

References

Ashraf, H., Colombo, J. P., Marcucci, V., Rhoton, J., & Olowoyo, O. (2021). A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management. Cureus, 13(11), e19764. https://doi.org/10.7759/cureus.19764

Gallaher, J. R., & Charles, A. (2022). Acute Cholecystitis: A Review. JAMA, 327(10), 965–975. https://doi.org/10.1001/jama.2022.2350

Manu, P., Rogozea, L. M., Sandor, V., & Dumitraşcu, D. L. (2021). Pharmacological Management of Peptic Ulcer: A Century of Expert Opinions in Cecil Textbook of Medicine. American journal of therapeutics, 28(5), e552–e559. https://doi.org/10.1097/MJT.0000000000001439

Sakalihasan, N., Michel, J. B., Katsargyris, A., Kuivaniemi, H., Defraigne, J. O., Nchimi, A., Powell, J. T., Yoshimura, K., & Hultgren, R. (2018). Abdominal aortic aneurysms. Nature reviews. Disease primers, 4(1), 34. https://doi.org/10.1038/s41572-018-0030-7

Vaghef-Davari, F., Ahmadi-Amoli, H., Sharifi, A., Teymouri, F., & Paprouschi, N. (2019). Approach to Acute Abdominal Pain: Practical Algorithms. Advanced journal of emergency medicine, 4(2), e29. https://doi.org/10.22114/ajem.v0i0.272

Yamashita, S., Tago, M., Katsuki, N. E., Nishi, T. M., & Yamashita, S. I. (2020). Relationships between sites of abdominal pain and the organs involved: a prospective observational study. BMJ open, 10(6), e034446.