Hits: 6
Lab 1 SOAP Note For Abdominal Pain(We offer assignment help )
Subjective:
CC: “Abdominal Pain”
SOAP Note For Abdominal Pain.HPI: 64-year-old male with chief complaint of “abdominal pain”. The sharp epigastric pain began 2 days ago, on the upper middle section of the abdomen that seems to be spreading at the back. The first occurrence of the pain was 2days ago as he was signing divorce papers at his work place. The pain has been continuous and feels like a burning sensation in his belly through his back. He reports that it gets worse when he coughs or makes any movement and feels better when he lies still and draws his legs up. He reports 8/10 pain severity. He reports that on the first occurrence the pain came back at night and it lasted for 1-2hrs after he took some “term “drugs. is the first occurrence. Denies diarrhea, vomiting, anorexia. Denies fever, chills, weakness, nausea, shortness of breath. Tried Morphine and Adphil with no relief.
Medical History: The patient has been not been hospitalized for any stomach or abdominal pains before. He reports that he had stomach pains 6months ago which had been on and off.
- Current Medications: The patient is currently using no medications.
- Allergies: No allergies
Family history: The patient is recently separated from his wife.
Social history: The patient works as stock broker which is pretty stressful but does not live with his wife. He smokes one and a half pack of cigarettes per day. He states that he takes 4-6 beers a day or drink 2-4 times a day and has done so since college. He says that he is concerned with his drinking though he does not want to discuss about it.
Review of Systems
Constitutional: denies anorexia and weight loss
HEENT: denies decreased hearing blurring, irritation, discharge, vision loss, eye pain, ear pain or discharge, nasal obstruction or discharge, nosebleeds, sore throat, hoarseness, dysphagia
Cardiovascular: denies chest pains, palpitations, orthopnea, PND, edema
Respiratory: denies cough and wheezing
Gastrointestinal: denies dark stool.
Genitourinary: denies blood in urine
Musculoskeletal: denies other 4 joint pain, joint swelling, muscle cramps, muscle weakness, stiffness,
Skin: denies rash, dryness, suspicious lesions
Neurologic: denies transient paralysis, paresthesias, seizures, syncope, tremors, vertigo Psychiatric: He reports mental disturbance from his work and recent divorce from his wife. denies depression, anxiety, memory loss.
Endocrine: denies cold intolerance, heat intolerance, polydipsia, polyphagia, polyuria
Heme/lymphatic: denies bruising, bleeding, enlarged lymph nodes
Allergic/Immunologic: denies hay fever, persistent infections
Objective:
Physical Examination
Vitals Signs: Temperature: 100.8, Heart Rate: 110, Blood Pressure: 140/88, Pain Score: 8/10 with localization of the pain in the epigastric area.
General: The patient’s physical well-being is okay though he seems moody and much disturbed about the pain. Pt denies trauma or asterixis common in alcohol withdrawal
HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions.
NECK: Supple. No lymphadenopathy. No thyromegaly.
LUNGS: Clear to auscultation and percussion bilateral.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.
ABDOMEN: tender, not distended. Splenomegaly normal. No hepatomegaly. Bowel sounds present.
MUSCULOSKELETAL: No cyanosis, no clubbing, no pitting edema.
Neurologic Nonfocal. No asterixis. No costovertebral tenderness.
Mental Status Exam: Judgment and insight intact; oriented to time, place, and person; intact memory for recent and remote events; no depression.
PSYCHE: The patient is oriented x4, alert and cooperative.
Pertinent Diagnostic Tests:
- CBCd/Complete Metabolic Panel: Serum alcohol level, urine toxicology, amylase and lipase liver function tests.
- Endoscopy (EGD) with mucosal biopsy: To detect the presence of mucosal irritation (gastritis)
- Abdominal Ultrasound: To assess the size of the liver
- Abdominal CT scan: To show increased aortic width or hydroureter if present.
Diagnostic results:
The patient’s body temperature is 100.8 °F, which is higher than average an indication of alcohol withdrawal. His blood pressure is 140/88 mm Hg, which is also higher than average. He has a heart of 110 and 122 breathing per minute, which is also higher than average. Abdominal palpation revealed pain when pressed down with epigastric and liver tenderness.
Assessment:
The patient appears comfortable and ready for the physical examination. He is cooperative though moody when the pain begins. He seems disturbed with the pain and shows dire need for something to relieve the pain. The patient has no record of previous hospitalization or surgery. He is currently using Morphine and Adphil to deal with the persisting pain though it does not help much.
Differential Diagnosis(SOAP Note For Abdominal Pain)
- Alcoholic gastritis
Alcoholic gastritis is when alcohol damages the stomach lining and can cause a variety of symptoms from abdominal pain to vomiting. Gastritis has many possible causes like eating spicy foods, smoking, stress, diseases that attack your body’s autoimmune system, bacterial or viral infections, trauma, pernicious anemia (when your stomach has problems handling vitamin B12), and reactions to surgery (Elseweidy, 2017). According to Chen & Haber, (2021), Alcoholic gastritis also results caused by drinking too much, too often. The alcohol can gradually irritate and erode your stomach lining which triggers gastritis symptoms. These symptoms are present in the patient, and the physical examination revealed that the patient exceeds the recommended drinking level for men of less than 14 drinks a week and less than 4 drinks on any one occasion since he takes 4-6beers a day or 2-4drinks a day. The said triggers are possible causes of the disease such as stress from his work as a stock broker and the fact that he recently separated with his wife, spicy foods and excessive alcohol consumption. These symptoms suggest that the patient is likely to be suffering from this condition. The patient has an elevated heart rate of 110 which is a sign of possible alcohol withdrawal.
- Peptic ulcer
A peptic ulcer is a sore that forms when digestive juices wear away the lining of the digestive system. A peptic ulcer can occur in the lining of the stomach, duodenum, or lower part of the esophagus. Symptoms can include indigestion-like pain, nausea, and weight loss (Dunlap & Patterson, 2019). The pain can often be relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication, but then it may come back. The pain may be worse between meals and at night. Stress and spicy foods do not cause peptic ulcers. However, they can make your symptoms worse. Rarely, ulcers can cause severe signs and symptoms, such as: vomiting blood, black and tarry stools, or stools with dark red blood, nausea and vomiting that is especially persistent and severe. The patients reports that the major triggers to the pain are stress and spicy foods which do not cause this condition. Further the patient has no stains in his stool or urine as symptoms of the disease.
- Acute pancreatitis
Acute pancreatitis means inflammation of the pancreas that develops quickly. The main symptom is tummy (abdominal) pain. It usually settles in a few days but sometimes it becomes severe and very serious. The most common causes of acute pancreatitis are gallstones and drinking a lot of alcohol (Ismail & Bhayana, 2017), More symptoms are severe left upper quadrant pain is more typical in pancreatitis, at times causing the patient to double over. The pain is persisting and radiates to the back but the location of the pain is not typical in pancreatitis, at times causing the patient to double over. Other common causes include excessive alcohol use, genetic conditions, and the use of certain medications. Though the patient has high alcohol intake and his temperature is slightly elevated, he does not reveal the other major symptoms associated with this condition.
Reflections:(SOAP Note For Abdominal Pain)
The patient presented symptoms of abdominal pains with elevated temperature a sign of alcohol withdrawal. Also, he confessed to have accrued stress from his nature of work as a stocks broker and the fact that he recently separated from his wife. From the cage analysis, it evident that he drinks alcohol excessively exceeding the recommended drinking level for men of less than 14 drinks a week and less than 4 drinks on any one occasion since he takes 4-6beers a day or 2-4drinks a day. He further confessed that some of the triggers to the pain spicy foods which he tries to avoid and the current stress factors. These symptoms suggest that the patient has a alcoholic gastritis. The patient is more likely to be suffering from alcoholic gastritis because the presented symptoms fit this condition. Going through this case study made me realize the importance of conducting a thorough physical examination rather than relying on the information provided by a patient. For example, a physical examination allowed the examiner to point out changes in the heart rate and other urinary tract stains.
Although the patient stated that he smokes one and a half packs of cigarettes a day and taking 4-6beers a day, the doctor should avoid judging the patient or questioning his behavior. Instead, a doctor should advise the patient to see a therapist because smoking and alcoholism might be one of the root factors causing his epigastric problems.
Case Formulation and Treatment Plan:
The patient was diagnosed with alcoholic gastritis. However, more tests will be required to ascertain that the patient is suffering from this condition. These tests will include abdominal x-ray and CT scan to assess the size of the liver and the aortic width. Once the patient is diagnosed with alcohol-related gastritis or is suspected to have this condition, medication such as proton pump inhibitors, to reduce the acid levels in your stomach may be prescribed. Also eating small meals more frequently, while avoiding triggers that can further irritate your stomach (such as drinking alcohol or eating acidic/spicy foods).
Further recommendations include abstain from alcohol and if the patient is struggling with abstaining from alcohol, they may attend professional treatment to overcome addiction, attend rehab which can also be a good way to avoid experiencing future health issues due to alcoholism. Alcoholic gastritis symptoms can be treated successfully with time, abstinence from alcohol, and the proper medication.SOAP Note For Abdominal Pain.