Pain in the abdomen can be paroxysmal or chronic, acute or dull, aching or cutting. Its causes may be different and include gallbladder disease, stomach ulcers, food poisoning, diverticulitis, appendicitis, pancreatitis, cancer, gynecological diseases, and problems with the cardiovascular system (Mills & Chen, 2011). While determining the abdominal pain, a nurse should collect the history of a patient’s illnesses, conduct a medical examination, both subjective and objective, and offer to undergo tests.
Evaluating SOAP Note Case Study
Additional Subjective and Objective Documentation
The subjective information regarding the given patient seems to be detailed yet incomprehensive. It is essential that a nurse makes notes about the patient’s PMH, HPI, FH, medications, and allergies. However, it would be better if data about the patient’s appetite, dietary habits, and changes in BMI was collected (Sullivan, 2012). More to the point, one may state that the nature of the abdominal pain is documented poorly. For instance, it is necessary to include its type, duration, exacerbating and alleviating factors, as well as hernias, ulcers, or any other previous associated diseases (Seidel et al., 2011). Considering that pain is located in the upper left quadrant of the abdomen, it is important to gather information about GU system, including voiding, nocturia, dysuria, and any other abnormal symptoms.
As for the objective data that should be collected directly by a nurse during the examination, there is auscultation and palpation, yet a lack of proper inspection and percussion. It would be better if such information as color, venous networks, abdominal reflexes, and other issues were revealed. In addition, symmetry, contour, additional sounds, tympany, dullness, etc. should be enumerated. The assessment is supported by both objective and subjective information since the nurse lists the patient’s social issues and provides the brief review of other body systems.
Diagnostic Tests and Results
In order to identify the diagnoses, a nurse used CAT scan that revealed pancreatic cancer. However, as noted by Ball, Dains, Flynn, Solomon, and Stewart (2015), gastrointestinal endoscopy should be prescribed to the patient to either detect or reject the existence of any related diseases. A colonoscopy is another option for the given patient to examine the abnormal pain in the abdomen to be biopsied (Dains, Baumann, & Scheibel, 2016). The latter would be beneficial to identify the exact cause of the pain. Among the laboratory tests that should be conducted, one may note a complete blood test and urinalysis as the most common tests to define inflammation. In addition to CAT, capsule enteroscopy or endoscopic ultrasound may be applied to specify the essence, location, size, and severity of the disease. The results of the mentioned tests should be considered in combination to determine a correct diagnosis.
Considerations Regarding Current Diagnosis
The initial diagnosis, pancreatic cancer, seems to be approved in the course of the examination and diagnostic tests. The following differential diagnoses (DDx) may be identified:
- Pancreatic cancer. While diagnosing pancreatic cancer, it is essential to pay particular attention to general symptoms such as abdominal or back pain, loss of appetite, fatigue, digestive problems, gallbladder enlargement, deep vein thrombosis, pulmonary embolism, etc. (Nakamura, Masuda, Harada, Akioka, & Sako, 2013). The onset of pancreatic cancer is characterized by an asymptomatic course. Some of the most common symptoms may be minor, including nausea, eructation, diarrhea, a lack of appetite, and weight loss.
- Pancreatic cysts. This is formation in the parenchyma of the body filled with fluid content, which develops due to traumatic or inflammatory damage to the pancreas (Craig & Infante, 2011). Symptoms depend on the size, location, and causes and range from a feeling of discomfort to severe pain syndrome (Vege et al., 2015).
- Chronic diverticulitis. An acute form of the disease that was diagnosed in the given patient can pass into chronic recurrent diverticulitis. In this case, the following symptoms occur: periodic severe pain in the projection of the inflamed bowel area; in most cases, the sigmoid colon is affected (Tursi et al., 2014).
Conclusion
To conclude, this case study was helpful to examine and diagnose the abdominal pain and set differential diagnoses. Based on the current literature, three differential diagnoses were provided for the given patient such as pancreatic cancer, pancreatic cysts, and chronic diverticulitis. It was revealed that significant additional subjective and objective data is required to reject or verify the initial diagnoses. Along with CAT, gastrointestinal endoscopy, colonoscopy, as well as capsule enteroscopy or endoscopic ultrasound were recommended to distinguish between the diagnoses.
Summary
The given SOAP case study presented incomprehensive patient examination regarding both objective and subjective data. The latter should also involve the patient’s dietary habits, appetite, and changes in BMI as well as more abdominal pain characteristics such as duration, type, exacerbating and alleviating factors, etc. Among the required objective information, one should enumerate percussion and inspection data, namely, venous networks, color, abdominal reflexes, symmetry, and so on. The diagnosis of pancreatic cancer was supported by the evidence, while differential diagnoses included pancreatic cysts and chronic diverticulitis.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Craig, M., & Infante, S. (2011). Abdominal mysteries: Pain, peritonitis, pancreatitis. Nephrology Nursing Journal, 38(2), 173-186.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Mills, A. M., & Chen, E. H. (2011). Abdominal pain in special populations. Emergency Medicine Reports, 32(7), 81–91.
Nakamura, T., Masuda, K., Harada, S., Akioka, K., & Sako, H. (2013). Pancreatic cancer: Slow progression in the early stages. International Journal of Surgery Case Reports, 4(8), 693-696.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical exam summary: Abdomen. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F. A. Davis Company.
Tursi, A., Elisei, W., Inchingolo, C. D., Nenna, R., Picchio, M., Ierardi, E., & Brandimarte, G. (2014). Chronic diverticulitis and Crohn’s disease share the same expression of basic fibroblastic growth factor, syndecan 1 and tumour necrosis factor-α. Journal of Clinical Pathology, 67(9), 844-846.
Vege, S. S., Ziring, B., Jain, R., Moayyedi, P., Adams, M. A., Dorn, S. D.,… Kosinski, L. R. (2015). American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology, 148(4), 819-822.