Introduction
The abdomen, a critical region of the human body, houses numerous vital organs, each
with their unique function and potential pathologies (Ball, & et al., 2023). Accurate assessment
of this region is crucial in healthcare, and one of the most effective tools for this purpose is the
SOAP (Subjective, Objective, Assessment, and Plan) note (Dains, Baumann, & Scheibel, 2019).
This paper aims to delve into the creation of an episodic SOAP note for abdominal assessment,
using a case study as a practical example.
The case study will be analyzed in detail, focusing on the presentation of subjective
details and the objective data gathered. This will include:
Subjective details: These are the patient's complaints, symptoms, and medical history.
Objective data: This includes physical examination findings, laboratory results, and other
measurable data.
We will also discuss additional subjective and objective information that should be
included in the documentation, enhancing the comprehensiveness and accuracy of the SOAP
note.
The paper will then explore whether the assessment findings are supported by subjective
and objective information. This is crucial as it ensures the validity of the assessment and the
subsequent diagnosis.
Next, we will identify the diagnostic tests that would be appropriate for the case.
Diagnostic tests are essential tools that provide further objective data, aiding in the confirmation
or rejection of a potential diagnosis. We will also discuss how the results of these tests would be
used to make a diagnosis
The paper will then provide an explanation of the acceptance or rejection of the given
diagnosis. This process is critical in ensuring the correct treatment plan is implemented for the
patient.
Finally, we will identify three possible conditions that may be considered as a differential
diagnosis for this patient. Differential diagnosis is a critical step in the diagnostic process, as it
considers all possible conditions that could cause the patient's symptoms and helps narrow down
to the most likely cause.
The Case Study
Subjective:
CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3
days ago. He has not taken any medications because he did not know what to take. He
states the pain is a 5/10 today but has been as much as 9/10 when it first started. He
has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10
units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN,
Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:
VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
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