Episodic SOAP Assessment: Abdominal Pain

In this Lab Assignment, you will analyze an Episodic note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients as well as which physical exams and diagnostic tests should be conducted. Formulate a five differential diagnosis based on the assessment data. Use more StatPearls and 3 different scholarly resources.

  • 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.
  • 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.
  • 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 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.

 

Review the Episodic note case study provided:

ABDOMINAL ASSESSMENT

A male went to the emergency room for severe mid-epigastric abdominal pain. He was diagnosed with AAA; however, the doctor ordered a CTA scan as a precaution. 

Because of the high potential for misdiagnosis, determining the precise cause of abdominal pain can be time-consuming and challenging. By analyzing case studies of abnormal abdominal findings, nurses can prepare themselves to better diagnose conditions in the abdomen. Missing key findings due to improper assessment can lead to error and potentially patient death.

 

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-day history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care, where he was given PPIs 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 him 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:

  1. Abdominal Aortic Aneurysm (AAA)
  2. Perforated Ulcer
  3. Pancreatitis

Answer

Episodic SOAP Assessment: Abdominal Pain

Subjective Portion Analysis

L.Z. is a 65-year-old African American male patient who has presented to the emergency department (E.D.) with epigastric pain for two days. He describes the abdominal pain as intermittent and reports it radiates to the back. He claims to be seeking medical intervention at Local Urgent Care, but there has been no relief of the pain despite a prescription for proton pump inhibitors (PPIs). He claims he has come to the E.D. because the pain has become severe. The patient reports an episode of post-prandial vomiting after lunch that triggered him to come for treatment. He reports no history of fever, diarrhea, or constipation. L.Z. is hypertensive and on metoprolol 50mg. He has no known food or drug allergy. His family history is positive for hypertension, hyperlipidemia, and gastroesophageal reflux disease. Under his social history, he has been drinking alcohol and smoking for 20 years, but he stopped two years ago. He divorced his wife five years ago, with whom they have two sons and one daughter. 

Additional information is finding the severity of the pain under the pain scale of 1-10, how it started, if it was acute in onset, the timing, if worse at daytime or nighttime, what is aggravating the pain, and any history of loss of consciousness or headache. Did anything provoke the pain, like trauma? Describe the vomitus, amount, bloody, bilious, or non-bilious. Under medical history, has he ever been admitted before? The family history should indicate which relatives are immediate or distant. Review of systems such be included from general to systems like cardiovascular, gastrointestinal, and musculoskeletal systems. The essence of subjective information is to aid one in obtaining a comprehensive history from the patient to identify all symptoms to come up with a diagnosis. 

Objective Portion Analysis

His vital signs are temperature 98.2F, Blood pressure 91/60mmHg, Respiratory rate 16, pulse rate 76, height 6’10’, and weight 262lbs. Upon calculating his body mass index, it is 27.4, indicative of being overweight (Weir & Jan, 2022). The other vital signs are within normal ranges. On cardiovascular exam, his radial pulse is of regular rhythm, and blood pressure is normal, normoactive precordium, and no murmurs auscultated. On respiratory exam, the chest wall is symmetrical. There should be a comment on chest expansion, tracheal position, and auscultation of the chest.

The integumentary system is intact, with no lesions, urticaria, or angioedema. The abdomen has epigastric tenderness and guarding, but there is no mass palpated or rebound tenderness. Since the abdomen is of much concern in this patient, there should be a systematic report of findings on inspection, palpation (both light and deep), percussion, and auscultation. Auscultation is helpful to pick bowel sounds or any bruit. 

Other information on objective assessment includes the general appearance of the patient, especially alertness, mood, nutritional status, and commenting if the patient is in obvious pain or distress. Provide systematic data of all systems following IPPA as mentioned above for other systems. Other regions to be mentioned include Head, Eyes, Ears, Nose, and throat (HEENT). 

Assessment

From the subjective and objective data provided above, this patient has an acute abdomen. The suggested differentials include Abdominal Aortic Aneurysm (AAA), perforated ulcer, and pancreatitis. 

Shaw et al. (2020) define an abdominal aortic aneurysm as an abnormal focal dilatation of the abdominal aorta. Most AAA are asymptomatic and only become symptomatic when they enlarge and may rupture, becoming life-threatening. On enlarging, AAAs present with abdominal pain with involvement of the flanks and the back. Upon palpation of the abdomen, a pulsatile mass is detected, which is painless. Ruptured AAAs cause acute abdominal pain, guarding, abdominal distension, and signs of peritonitis. Patients may also collapse. Risk factors for AAA in this patient include male sex, many years of smoking, physical inactivity due to overweight, advanced age (65 years), being that he is hypertensive, overweight, and a family history of hyperlipidemia; he would have atherosclerosis (Shaw et al., 2020). Atherosclerosis is a significant risk for AAAs and is precipitated by genetic factors, hypertension, hyperlipidemia, smoking, alcohol, and advanced age, which are all in this patient (Pahwa & Jialal, 2019). 

According to Stern et al. (2022), the typical presentation of perforated ulcers is sudden severe epigastric pain. Patients will report the pain to be localized initially before radiating to all abdominal quadrants to be diffuse. Examination findings include tenderness, guarding, and rigidity. Other signs and symptoms may include syncope and lightheadedness associated with hemorrhage, awareness of heartbeat, bloating, and dyspnea (Stern et al., 2022). Pancreatitis can be acute on chronic. In this case, the differential will be acute pancreatitis. Acute pancreatitis presents with acute abdominal pain following a history of binge alcohol drinking. Another significant risk factor of acute pancreatitis is gallstones (Gapp & Chandra, 2022). The pain is sharp and cannot be relieved by PPIs. The patient has no history of binge alcohol intake or gallstone disease; therefore, the differential is not appropriate. 

Diagnostic Tests

  1. Abdominal CT scan. Effective in showing the location and size of AAA.
  2. Abdominal Ultrasound. This is a rapid test that can show the location and thus diagnose AAA. 
  3. C.T. angiography (CTA). This is an effective modality for investigating aneurysms. It will show the location of AAA. 
  4. Complete blood count is a routine test to check for hemoglobin levels to detect any ongoing bleeding. 
  5. Conduct serum lipase and amylase levels to rule out acute pancreatitis. 
  6. Erect Chest X-ray, or lateral decubitus, is diagnostic of the perforated viscus by showing air under the diaphragm. 

(MD, 2021)

Primary Diagnosis

Abdominal Aortic Aneurysm 

This is the most appropriate diagnosis for L.Z., and I agree with it. The patient has a history of persistent epigastric pain for two days. Most AAA are asymptomatic, and those with symptoms will report abdominal, back, and limb pain, which mainly develops as a result of distal ischemia. When reviewing the risk factors of AAA, L.Z. has most of them. AAA is associated with advanced age, male gender, smoking, alcohol use, hypertension, hyperlipidemia, or a history of the two (Hellawell et al., 2020). L.Z. is aged 65, is male, hypertensive, smoking and alcohol use, and has a history of hypertension and hyperlipidemia. On palpation of the abdomen, a pulsatile mass can be felt in the epigastric region (above the umbilical level.) It was impossible for a mass to be palpated in L.Z. because of his overweight, indicated by a BMI of 27.4; however, diagnostic tests such as CTA and abdominal ultrasound confirmed the diagnosis. 

Differential Diagnosis

Perforated Peptic Ulcer 

An ulcer is defined as a mucosal erosion (Malik & Singh, 2023). Upon breaking through the stomach or duodenal wall, it perforates, thus becoming a perforated peptic or duodenal ulcer. Patient with complaints of severe epigastric pain that is of acute onset and associated with night awakening. Signs and symptoms include fever, tachycardia, hypotension, and shock. Predisposing factors include peptic ulcer disease (PUD), which eventually perforates. Factors promoting PUD include smoking, stress, chronic nonsteroidal anti-inflammatory (NSAID) use, and Helicobacter pylori infection (Malik & Singh, 2023). On abdominal examination, the patient has epigastric pain and guarding. The patient will respond to PPIs as this is the mainstay of management for PUDs. 

Acute Cholecystitis 

It is inflammation of the gall bladder, and it presents with right upper quadrant pain (Jones et al., 2019). It is a differential of acute abdomen and occurs in patients with gallstones. It is a common finding in women of reproductive age who are overweight and below forty years (Jones et al., 2019). L.Z. is less likely to have acute cholecystitis due to the lack of the mentioned risk factors. 

Acute Pancreatitis 

Gapp & Chandra (2022) define acute pancreatitis as acute inflammation of the pancreas, which causes acute abdominal pain. Risk factors include alcohol, gallstones, mumps, toxins, and trauma (Gapp & Chandra, 2022). In most cases, upon presentation, especially in men, they will report a history of binge alcohol intake the previous night. The patient, having stopped alcohol two years ago, is less likely to have developed acute pancreatitis. 

Acute Mesenteric Ischemia 

This is caused by an interruption of normal blood flow by either thrombosis, low velocity, or an embolus (Monita & Gonzalez, 2021). It causes out-of-proportion pain in patients; thus, it is a cause of an acute abdomen. Findings include abdominal tenderness, absence of bowel sounds on auscultation, rigidity, and guarding (Monita & Gonzalez, 2021). This is a possible differential. 

Intestinal Obstruction

Refers to obstruction of the normal transit of intestinal contents (Smith & Nehring, 2018). The causes may be dynamic or adynamic. Some causes of intestinal obstruction include adhesions, gallstones, bezoars, and adynamic causes like hypokalemia, which causes ileus (Smith & Nehring, 2018). Patients present with vomiting, constipation, dehydration, abdominal distension, and obstipation. The patient has no findings suggestive of intestinal obstruction. 

Conclusion

Approaching patients with acute abdomen requires thorough history taking, physical examination, and appropriate diagnostic tests to make a diagnosis as early as possible. Most causes of acute abdomen can be life-threatening if not detected early for appropriate management interventions. Some of the causes of acute abdominal pain include abdominal aortic aneurysm, acute pancreatitis, and perforation of a viscus.

References

Gapp, J., & Chandra, S. (2022). Acute Pancreatitis. StatPearls. https://www.statpearls.com/articlelibrary/viewarticle/26578/

Hellawell, H. N., Mostafa, A. M. H. A. M., Kyriacou, H., Sumal, A. S., & Boyle, J. R. (2020). Abdominal aortic aneurysms part one: Epidemiology, presentation and preoperative considerations. Journal of Perioperative Practice, 175045892095401. https://doi.org/10.1177/1750458920954014

Jones, M. W., Genova, R., & O’Rourke, M. C. (2019). Acute Cholecystitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459171/

Malik, T. F., & Singh, K. (2023, February 12). Peptic Ulcer Disease. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534792/

MD, G. M. (2021). Abdominal aortic aneurysm – Symptoms, diagnosis and treatment | BMJ Best Practice. Bestpractice.bmj.com. https://bestpractice.bmj.com/topics/en-gb/3000088

Monita, M. M., & Gonzalez, L. (2021). Acute Mesenteric Ischemia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK431068/

Pahwa, R., & Jialal, I. (2019, April 17). Atherosclerosis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507799/

Shaw, P. M., Loree, J., & Gibbons, R. C. (2020). Abdominal Aortic Aneurysm (AAA). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470237/

Smith, D. A., & Nehring, S. M. (2018). Bowel Obstruction. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441975/

Stern, E., Sugumar, K., & Journey, J. (2022). Peptic Ulcer Perforated. StatPearls. https://www.statpearls.com/articlelibrary/viewarticle/26938/

 

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