write 3 pages of SOAP note with 5 to 6 sources on the following case study.
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-day history of
intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent
Care where 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 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:
1. Abdominal Aortic Aneurysm (AAA)
2. Perforated Ulcer
3. Pancreatitis
PLAN:
