It is essential to consider the likelihood of a condition, physical exam, imaging studies, and past medical history when assessing abdominal issues, including diarrhea, vomiting, or abdominal pain. In case of abdominal pain, it is crucial to identify the pain location. According to Ball et al. (2019), the patient should be supine when performing abdominal exams. This paper will review the subjective and objective parts of the assigned episodic soap note and outline additional information that should be incorporated. It will also identify if the subjective and objective information supports the assessment and the required diagnostic tests.
Analysis of the Subjective Portion
The chief complaint in the episodic note includes abdominal pain. Thus, the history of the present illness should include the location of abdominal pain. The practitioner should also inquire about the characteristics of the abdominal pain and its timing. For example, does the abdominal pain worsen after meals or during the night or morning? The practitioner should ask the patient to rate his stomach pain on a scale of 0 to 10 or 1 to 10 to determine the severity of the stomach pain.
Additional Information that Should Be Included in the Documentation
HPI
The characteristics, nature, location, timing, and severity of the stomach pain should be included in the HPI part. Factors that worsen or relieve that stomach pain should also be identified.
Social History
The patient’s dietary pattern, leisure activities, family support, alcohol consumption, drug and substance abuse, and living arrangement should be considered in this section.
Past Surgical History
The practitioner should ask the patient about significant surgical history, including small bowel resection or cholecystectomy.
Sexual Reproductive History
The practitioner should ask the patient about the number of sex partners and the use of sex protection.
ROS
ROS components that should be considered in the focused episodic note include constitutional symptoms related to the chief complaint, HEENT, cardiovascular, respiratory, and gastrointestinal. The practitioner should ask the patient about factors associated with his chief complaint, including diarrhea, indigestion, history of GERD, or anorexia.
Analysis of the Objective Portion
Additional Information that Should Be Included in the Documentation
The practitioner should identify the patient’s general appearance, including alertness and orientation, eye contact, dressing, and cooperation. The practitioner should also take the vitals of this patient. Physical exam for this patient should focus on HEENT, chest/lungs, cardiovascular, and abdomen. Thus, the practitioner should inspect, percuss, palpate, and auscultate his abdomen while supine to identify or rule out factors like distension, tenderness, or masses. It also helps the practitioner to identify bowel sounds and other factors that can be useful in diagnosing the patient.
Does the Subjective and Objective Information support Assessment?
The primary diagnosis includes the Abdominal Aortic Aneurysm (AAA). Abdominal Aortic Aneurysm is marked by sudden stomach pain, nausea, and vomiting (Lattanzi, 2020). The patient reports worsening stomach pain for the past two days, accompanied by vomiting. The condition is also common in older adults.
Diagnostics Tests that Would be Appropriate for this Case and How the Results Would Be Used to Make a Diagnosis
A complete blood count (CBC) would be needed to confirm/rule out blood disorders that could be associated with the patient’s symptoms, including stomach pain (Daldal & Dagmura, 2020). According to Fraij et al. (2020), a stool culture is useful in confirming or ruling out the presence of bacterial infections that could cause the patient’s symptoms. A urea breath test would be required to identify or rule out the presence of Helicobacter pylori associated with conditions like ulcers that can cause symptoms like stomach pain (Jambi, 2022). An abdominal CT scan would be required to evaluate abdominal organs and other structural abnormalities that could be associated with stomach pain (Carpenter et al., 2021).
Would You Reject or Accept the Current Diagnosis? Why or Why Not?
The subjective and objective data support the diagnosis. Therefore, I would accept the current diagnosis. According to Lattanzi (2020), patients with AAA present with acute stomach pain accompanied by nausea and vomiting. Possible differential diagnoses for this case include acute gastritis, appendicitis, diverticulitis, peptic ulcer disease, and small bowel obstruction.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Carpenter, C. R., Griffey, R. T., Mills, A., Doering, M., Oliveira J. e Silva, L., Bellolio, F., Upadhye, S., & Broder, J. S. (2021). Repeat computed tomography in recurrent abdominal pain: An evidence synthesis for guidelines for reasonable and appropriate care in the emergency department. Academic Emergency Medicine, 29(5), 630–648. https://doi.org/10.1111/acem.14427
Daldal, E., & Dagmura, H. (2020). The correlation between complete blood count parameters and appendix diameter for the diagnosis of acute appendicitis. Healthcare, 8(1), 39. https://doi.org/10.3390/healthcare8010039
Fraij, O., Castro, N., de Leon Castro, L. A., & Brandt, L. J. (2020). Stool cultures show a lack of impact in the management of acute gastroenteritis for hospitalized patients in the Bronx, New York. Gut Pathogens, 12(1). https://doi.org/10.1186/s13099-020-00369-2
Jambi, L. K. (2022). Systematic review and meta-analysis on the sensitivity and specificity of 13c/14c-urea breath tests in the diagnosis of helicobacter pylori infection. Diagnostics, 12(10), 2428. https://doi.org/10.3390/diagnostics12102428
Lattanzi, S. (2020). Abdominal aortic aneurysms: Pathophysiology and clinical issues. Journal of Internal Medicine, 288(3), 376–378. https://doi.org/10.1111/joim.13060
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. https://doi.org/10.1136/bmjopen-2019-03444
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