THE ASSIGNMENT: Analyze the subjective portion of the note. List additional information that should be included in the documentation.

THE ASSIGNMENT

1. Analyze the subjective portion of the note. List additional information that should be included in the documentation.
2. Analyze the objective portion of the note. List additional information that should be included in the documentation.
3. Is the assessment supported by the subjective and objective information? Why or why not?
4. What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
5. Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references from current evidence-based literature.

**REMEMBER THIS IS AN ANALYSIS FROM EACH PART OF THE SOAP POINTING TO WHAT’S MISSING AND WHY DO YOU NEED THAT SECTION WITH SPECIFICS  JUSTIFYING AND EXPLAINING  EVERYTHING INCLUDING THE DIAGNOSIS

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 days history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPI’s 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