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.
**REMEMBER THIS IS AN ANALYSIS FROM EACH PART OF THE SOAP POINTING TO WHAT’S MISSING AND WHY DO YOU NEED THAT SECTION WITH SPECIFICS JUSTIFYING AND EXPLAINING EVERYTHING INCLUDING THE DIAGNOSIS
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.
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
***REFER TO ATTACH FILE FOR RUBRIC GUIDELINES THAT ARE TO BE FOLLOWED FOR GRADING***
Expert Solution Preview
Introduction:
This case study involves a patient who presents with complaints of epigastric pain for two days. The patient’s medical history includes hypertension and a current medication of metoprolol. The following analysis will provide additional information that should be included in the subjective and objective portions of the note, determine if the assessment is supported by subjective and objective information, identify appropriate diagnostic tests for this case, and evaluate the current diagnosis while identifying three possible conditions that may be considered as a differential diagnosis for this patient.
1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
In the subjective portion of the note, the patient reported having intermittent epigastric abdominal pain that radiates to the back for two days. However, there are some key elements missing that could aid in the diagnosis. The patient didn’t mention any worsening or improvement of the pain with meals or lying down. Information about the onset of pain, the character of the pain, and the severity of the pain could have been valuable in understanding the patient’s condition. The patient also didn’t report any previous episodes of abdominal pain or any other medical conditions that could have contributed to their current condition. The presence of any allergies to medications or a family history of any gastrointestinal disorders would have been beneficial to include in the subjective note.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
In the objective portion of the note, the vital signs of the patient were recorded along with an assessment of their heart, lungs, skin, and abdomen. While these observations describe some useful information, additional information that should be included in the documentation would be the patient’s bowel movements, appetite, and weight loss. It would also be crucial to note the patient’s age and sex, as the prevalence of certain gastrointestinal disorders differs between genders and generally increases with age. The patient’s medical history, which includes hypertension and hyperlipidemia, would also provide better insight into the patient’s condition.
3. Is the assessment supported by the subjective and objective information? Why or why not?
The assessment is not entirely supported by the subjective and objective information. While the patient reports having intermittent abdominal pain that radiates to the back for two days, there is little information about the nature of the pain. The patient’s current assessment of abdominal aortic aneurysm (AAA), perforated ulcer, or pancreatitis could be supported by the presence of epigastric abdominal pain, but more objective evidence and medical testing would be needed to support these conclusions further.
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
A computed tomography angiography (CTA) or ultrasound may be appropriate tests for this case. A CTA will determine if the patient has an AAA, which is the most critical diagnosis on the patient’s list. If the CTA were negative, an ultrasound could be used to diagnose pancreatitis. Still, other diagnostic tests, such as a stool test, blood work, or an endoscopy, may need to be performed to determine if the patient has a perforated ulcer.
5. 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.
Based on the current subjective and objective findings, I would accept the current diagnosis with caution. While the patient’s symptoms suggest that they may have an AAA, perforated ulcer, or pancreatitis, additional information and medical testing would be needed to confirm these diagnoses.
Three possible conditions that may be considered as a differential diagnosis for this patient are:
1) Gastrointestinal bleeding caused by gastritis or peptic ulcer disease (Gamble et al., 2015).
2) Gallstones, which can cause abdominal pain radiating to the back, fever, and chills (Mansour et al., 2019).
3) Acute cholecystitis, which presents similarly to gallstones with fever, chills, and right upper abdominal pain (Saber et al., 2018).
References:
Gamble, J., Krishnamurthy, M., & Robbins, J. (2015). Gastrointestinal Bleeding. Journal of Hospital Medicine, 10(9), 631-635. doi: 10.1002/jhm.2421
Mansour, H., Nasser, H., Yacoub, A., & Banafa, M. (2019). Gallstones. In StatPearls. StatPearls Publishing.
Saber, A. A., Boros, M. J., & Mancl, T. (2018). Patient factors associated with increased risk for complications after laparoscopic cholecystectomy: A review of 32,849 cases. Surgical Endoscopy, 33(2), 320-327. doi: 10.1007/s00464-018-6247-0
