Description
For the following case study, write this up as a narrative answering the following questions in detailed explanation with appropriate citations from the last 5 years (starting in 2019). Include an introduction with a purpose statement and conclusion. Use as many citations as needed. Please open the Word document for the rest of the instructions and required questions. I wrote most of the answers in red that you need to include in the answer. Also, include headers so I know which number of question you are answering.
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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:
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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
write this up as a narrative answering the following questions in detailed explanation with
appropriate citations from the last 5 years (starting in 2019). Include an introduction with a
purpose statement and conclusion. Use as many citations as needed.
1. Analyze the subjective portion of the note. List additional information that should be included in
the documentation. (details on any factors that may have triggered or worsened the pain,
Characterization of Pain, Temporal Pattern, Social and Environmental Factors)
2. Analyze the objective portion of the note. List additional information that should be included in
the documentation. (General Appearance, Neurological Examination, Pain Scale Assessment,
Abdominal Examination: Specify the location, nature, and intensity of the tenderness in the
epigastric area. Mention if the pain is exacerbated or relieved with palpation., Past Surgical
History, provide more details on guarding – is it voluntary or involuntary, and does it occur
throughout the abdomen or in specific areas?)
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? (choose additional diagnostic tests other than the ultrasound and CTA to
proof different diagnoses)
5. Would you reject/accept the current diagnosis? Why or why not? Identify three additional
conditions that may be considered a differential diagnosis for this patient. Explain your reasoning
using as many references as possible from current evidence-based literature.
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