Comprehensive Soap Note Essay on Abdominal Assessment
Subjective
CC: “My stomach pains me; I have continuous diarrhea. Nothing seems to help.”
HPI: RQ, 48 y/o male, complains of experiencing generalized abdominal pain for the last three days. He has not taken any medication, unsure if it would work. The patient reports that the pain has reduced to a 5/10 from 9/10 two days ago. His low appetite prevents him from eating properly, and he experiences some nausea afterward.(Comprehensive Soap Note Essay on Abdominal Assessment)
PMH: HTN, diabetes, hx of GI bleeding four years ago.
Medications: Amlodipine 5 mg, Lisinopril 10 mg, Metformin 100 mg, and Lantus 10 units qhs.
Allergies: NKDA
FH: History of DMT2 and colon cancer. The mother has a history of HTN, GERD, and Hyperlipidemia.
Social Hx: Occasional etoh, no tobacco use history, married with four children (2 boys, 2 girls).
Objective
VS: Temp 98.9, BP 161/86, RR 17, HT 5’12”, WT 252Ibs.
Heart: no murmurs, RRR.
Lungs: chest wall symmetrical, CTA.
Skin: no urticaria, intact with no lesions.
Abdomen: pos pain at the LLQ, hyperactive bowel sound, soft.
Diagnostics: US and CTA
Assessments: Abdominal Aortic Aneurysm (AAA), Perforated Ulcer, Pancreatitis
Analyze the subjective portion of the note. List additional information that should be included in the documentation
The subjective information of the SOAP note helps in disease assessment based on the information reported by the patient (Voukelatou et al., 2021). In the above subjective portion of the note, key areas covered include primary complaint, history of illness, medication history, current medication, social history, family history, and allergies. However, the physician needs to collect the following data to enhance the accuracy of the diagnosis:(Comprehensive Soap Note Essay on Abdominal Assessment)
- Character of pain
- Pain alleviating factors
- Frequency of food intake.
- Review of Systems (ROS)
- Skin
- Gastrointestinal
- Genitourinary
Analyze the objective portion of the note. List additional information that should be included in the documentation
The objective SOAP note provides information about the physician’s review of the patient’s problem (Anghel et al., 2019). In this case study, the objective SOAP focuses on the patient’s vital signs, heart activity, skin condition, lungs, and abdominal review. However, the following information should be included for a better diagnosis:(Comprehensive Soap Note Essay on Abdominal Assessment)
- Heart rate
- BMI
- The patient’s general appearance
- Mouth
- Psychiatric
- Respiratory performance
- Musculoskeletal and neurological information
Is the assessment supported by subjective and objective information? Why or why not?
Ideally, objective and subjective data should be consistent to facilitate the development of an appropriate diagnostic approach for the patient (Voukelatou et al., 2021). In the given case, both data helped in informing the assessment. Specifically, the subjective data supporting assessment are the patient’s chief complaints, his medical history, including past and present illnesses, and social and family history. On the other hand, objective data included in the assessment process are results from the abdominal review, which revealed the existence of pain in the left lower quadrant. However, the objective data was inadequate to support evaluation because it failed to include laboratory tests and information about the patient’s full body review.(Comprehensive Soap Note Essay on Abdominal Assessment)
What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
A complete blood count (CBC) would assess if the patient has abdominal infections. The CBC tests provide information about the patient’s cells’ health by indicating the white blood cells, red blood cells, and platelet counts (Powell & Wanhainen, 2020). Additionally, a liver enzyme test would assess the levels of specific enzymes and proteins in the patient’s blood. Furthermore, abdominal X-ray and abdominal X-ray ultrasound would evaluate the patient’s abdominal health. Lastly, a stool test is recommended to assess the possible presence of bacterium or parasites leading to diarrhea.(Comprehensive Soap Note Essay on Abdominal Assessment)
Would you reject/accept the current diagnosis? Why or why not? Identify three conditions that may be considered a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.
I would accept the AAA diagnosis at the beginning until additional tests are conducted because he complains of intermittent pain. However, the patient does not describe his pain as sharp, an important characteristic of AAA (Radonjic et al., 2020). The first differential diagnosis for this patient is acute pancreatitis as the primary diagnosis, which could be caused by hyperlipidemia. Powell and Wanhainen (2020) also claim that acute pancreatitis diagnosis can be initially conducted without imaging.(Comprehensive Soap Note Essay on Abdominal Assessment)
The second differential diagnosis is gastroenteritis, as the patient complains of constant stomach pain and diarrhea. Evidence from the study by White et al. (2019) shows that gastroenteritis is a very common condition that causes diarrhea and vomiting and is caused by a bacterial or viral tummy bug. Based on the patient’s symptoms, gastroenteritis would be considered for diagnosis. This condition results from a viral or bacterial infection of the bowel and stomach. The third differential diagnosis for this patient is gastritis, characterized by sudden onset epigastric pain and nausea. According to Hojo et al. (2021), gastritis is characterized by inflammation of the stomach lining. The patient experienced abdominal inflammation leading to diarrhea.(Comprehensive Soap Note Essay on Abdominal Assessment)
References
Anghel, L. A., Farcas, A. M., & Oprean, R. N. (2019). An overview of the common methods used to measure treatment adherence. Medicine and pharmacy reports, 92(2), 117-122.(Comprehensive Soap Note Essay on Abdominal Assessment)
Hojo, M., Nagahara, A., Kudo, T., Takeda, T., Ikuse, T., Matsumoto, K., … & Shimizu, T. (2021). Endoscopic findings of Helicobacter pylori gastritis in children and young adults based on the Kyoto classification of gastritis and age‐associated changes. JGH Open, 5(10), 1197-1202.
Powell, J. T., & Wanhainen, A. (2020). Analysis of the differences between the ESVS 2019 and NICE 2020 guidelines for abdominal aortic aneurysm. European Journal of Vascular and Endovascular Surgery, 60(1), 7-15.(Comprehensive Soap Note Essay on Abdominal Assessment)
Radonjic, A., Hing, N. N. F., Harlock, J., & Naji, F. (2020). YouTube as a source of patient information for abdominal aortic aneurysms. Journal of Vascular Surgery, 71(2), 637-644.(Comprehensive Soap Note Essay on Abdominal Assessment)
Voukelatou, V., Gabrielli, L., Miliou, I., Cresci, S., Sharma, R., Tesconi, M., & Pappalardo, L. (2021). Measuring objective and subjective well-being: dimensions and data sources. International Journal of Data Science and Analytics, 11, 279-309.(Comprehensive Soap Note Essay on Abdominal Assessment)
White, A. E., Ciampa, N., Chen, Y., Kirk, M., Nesbitt, A., Bruce, B. B., & Walter, E. S. (2019). Characteristics of Campylobacter and Salmonella infections and acute gastroenteritis in older adults in Australia, Canada, and the United States. Clinical Infectious Diseases, 69(9), 1545-1552.(Comprehensive Soap Note Essay on Abdominal Assessment)
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