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QUESTION
W7
W7.—2 pages---
SOAP format
Case:
A 25-year-old male graduate student is seen in the office with the chief complaint of upper abdominal pain. He states that he noticed the pain intermittently over the past several weeks. He notices that he gets a gnawing pain about 2 hours after he eats. He also notes that he has some bloating and occasional nausea with the pain. He states that the pain is relieved by antacids most of the time.
Then:
Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals and other team members needed to complete patient care.
| Subject | Nursing | Pages | 5 | Style | APA |
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Answer
CASE STUDY- Abdominal Pains
Subjective
Assessment of Patient History through Questions
The first approach is to take a patient history, I would spend a significant time crafting the narrative of illness and understand whether the events have anything to do with the current onset of symptoms.
- What is the quality and severity of the pain, and does the location change with time?
- How did the pain begin and what is the type and its pattern?
- How long does the pain last, and what worsens it?
- Do you have any allergies to certain foods or conditions?
- Are you an active smoker or a non-smoker?
- Have you had any changes in your dietary plans?
- Are you on any current medications?
- What is your bowel or urinary habit?
Objective
Physical Exam Elements
Further testing would assess vital signs such as heart rate (HR), blood pressure (BP), respiration rate (RR), pulse rate, and body temperature (Irwin, Barmherzig, & Gelfand, 2017). I would also recommend a HEENT (head, eyes, ears, nose, and throat) examination, with particular focus on the head to assess whether the skull is normal cephalic, atraumatic (NC/AT). I would also establish imaging tests such as stress echocardiography or stress radionuclide myocardial perfusion imaging after the physical tests suggest the likelihood of a health issue. It is vital to examine the presence of dyspnea, shortness of breath, chest pains, crackles, or tachypnea.
Assessment
Differential and Working Diagnosis
Abdominal pain can be caused by diverse factors such as mild constipation or life-threatening conditions such as acute MI or abdominal aortic aneurysm. Considering that several infections can present with abdominal pain, the key to establishing a differential diagnosis, in this case, would be to critically assess the history and physical exam (Irwin, Barmherzig, & Gelfand, 2017).
Pertinent Positives
From the case analysis, the patient experiences pain in the upper abdominal (epigastric) section, and myocardial infarction is, thus, considered a likely causal factor. Appendicitis is also a possible issue because it has lately presented in patients of ages 25 and 69 (Lacy, Parkman, & Camilleri, 2018). Findings of interest for myocardial infarction as the working diagnosis include the location of the pain in the upper parts of the body, gnawing pain, tightness, pressure, and aching sensations, occasional nausea, fatigue, and bloating due to issues of indigestion causing abdominal pains (Irwin, Barmherzig, & Gelfand, 2017).
Pertinent Negatives
The analysis rules out the possibility of ectopic pregnancy that might exhibit similar symptoms because this is a male patient. Bacterial gastroenteritis occurs due to gut infection, and in turn inflame the stomach and intestines. Although the symptoms are similar to what the patient was exhibiting such as abdominal cramps, vomiting, and diarrhea, this possibility is ruled out as the patient tests negative for gut infection.
Plan
Treatment Plans
The best complementary remedies and over the counter (OTC) medications include eating lesser food portions, reducing the amount of baking soda intake, using lemon or lime juice frequently, and avoiding smoking or drinking alcohol. Other health professionals might suggest the use of ginger, peppermint, chacomile tea, or licorice. Specific medications to control the pain include bismuth subsalicylate- Pepto-Bismol, loperamide, Imodium, or Zantac, among other OTC substances (Irwin, Barmherzig, & Gelfand, 2017). Some doctors would recommend antacids and appropriate anti-wind medications to help ease heartburn caused by bloating. However, patients must avoid taking ibuprofen or aspirin because they exacerbate the pains instead of controlling the adversity.
The medical doctors can recommend the best drug interventions to control abdominal pains and engage nutritionists to advise the patient on the best meal plans for controlling constipation and feelings of nausea. Physical assistants and nurses can help patients manage the signs and symptoms by complying with the suggested recommendations. Pharmacists can advise on the severity of some OTC drugs or therapies compared to others. The patient should be assigned to therapists and other rehabilitation specialists to help with pain management, and work closely with emotional support providers to help patients push through the tough times (Lacy, Parkman, & Camilleri, 2018). Referrals to these care teams remain vital to complete patient care and ease the severity of the condition and related pains.
References
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Irwin, S., Barmherzig, R., & Gelfand, A. (2017). Recurrent gastrointestinal disturbance: abdominal migraine and cyclic vomiting syndrome. Current neurology and neuroscience reports, 17(3), 21. Lacy, B. E., Parkman, H. P., & Camilleri, M. (2018). Chronic nausea and vomiting: evaluation and treatment. American Journal of Gastroenterology, 113(5), 647-659. |