Upper Abdominal Pain Soap Note Sample

Patient Presentation

Student’s Name

Institutional Affiliation

Course Name

Course Code

Instructor’s Name

Assignment Due Date

Patient Presentation

Patient Information

BM, 55-year-old, male, African American

Chief Complaint (CC): Upper abdominal pain

History of Presenting Illness (HPI)

BM is a 55-year-old, male, African American who came to the clinic complaining of upper abdominal pain. He was well until 1 month ago when he suddenly developed upper abdominal pain. The pain began as mild and has progressively increased in severity to moderate, rated 5 out of 10 on a pain scale. It is a dull aching and intermittent type of pain with no specific timing. It is associated with loss of appetite, early satiety, yellowness of the eyes and skin, occasional nausea and vomiting, and skin itchiness as well as hotness of the body. No known relieving and aggravating factors.

Upper Abdominal Pain Soap Note Sample

Past Medical and Surgical History

Denies past major illnesses and surgeries. Denies previous blood transfusions. All immunizations are current. No known food and drug allergies. Not hypertensive, not diabetic, HIV negative, and currently not on any medications.

Family Social History

A father of 3 children, all alive and well. He is a teacher and stays with his wife who is also a teacher. His father died of liver cancer. He denies smoking but reports taking alcohol since he was 18 years.

Review of Systems

HEENT: He reports occasional headache, yellow sclera, and face. Denies blurring of vision, double vision, ear pain, neck pain, hearing loss, ringing in the ears, sneezing, runny nose, or hoarseness.

Respiratory:  He denies chest pain, sputum production, difficulty in breathing, cough, and chest tightness.

Cardiovascular/Peripheral Vascular: He denies cough, breathlessness, awareness of heartbeat, fatigue.

Genitourinary: He reports no blood in urine, dysuria, frequent urination, and incontinence.

Musculoskeletal: Denies back pains, muscle pains, joint pains, and change in mobility.

Neurological: He reports occasional confusion and forgetfulness.

Psychiatric: He reports anxiety. No delirium and depression.

Skin/hair/nails: He reports skin itchiness but denies a history of eczema/atopic dermatitis, hair loss, or nail loss.

Physical Examination Findings

Vital signs: BP 115/78 mmHg, Temperature 100 F, HR 90bpm, RR 22 breaths/ min

General: Middle-aged African American male, sick looking but well hydrated, of good nutrition status, and not in any form of respiratory distress. There is palmar erythema, hepatic fetor, and jaundice of the sclera and facial skin. No conjunctival pallor, no central cyanosis, mild peripheral limb edema, and no cervical or inguinal lymphadenopathy.

Abdomen: Moderately distended abdomen, moves with respiration, no scars or spider naevi on inspection. Mild tenderness in the upper quadrant, hepatomegaly (liver span 13.5 cm) but no splenomegaly on palpation. Positive fluid thrill but negative shifting dullness on percussion. Bowel sounds are present.

Neurological: GCS 15/15, oriented to place, person, and time, memory is intact, intact sensory and motor function. Positive asterixis.

Cardiovascular: Normal jugular venous pressure, normal precordium, S1, S2 heard, and no added sounds.

Lymphatic system: Virchow node absent.

Differential Diagnosis

Alcoholic Hepatitis: Alcoholic hepatitis is a progressive inflammatory syndrome of the liver that occurs in chronic alcoholics (Patel & Mueller, 2021). BM presents with a history of alcohol intake for the last 37 years with obvious impairment in the liver function as evidenced by stigmata of liver disease such as jaundice, palmar erythema, upper quadrant abdominal pain, ascites, hepatomegaly, hepatic fetor, and asterixis (Patel & Mueller, 2021). Furthermore, he presents with occasional nausea and vomiting, fever, and loss of appetite which also accompany alcoholic hepatitis.

Cirrhosis: Cirrhosis which is characterized by periportal fibrosis is a common pathway for most chronic liver diseases can be a possible diagnosis. The patient has a history of chronic alcohol intake, a major risk factor for liver cirrhosis (Sharma & Nagalli, 2021). Findings such as confusion, forgetfulness, and asterixis suggest hepatic encephalopathy which is common in cirrhotic patients (Sharma & Nagalli, 2021). Ascites, jaundice, palmar erythema, hepatic fetor, and upper quadrant pain all suggest impaired liver function which is common in cirrhotic patients.

Chronic Hepatitis B or C Disease: BM manifestations of chronic liver disease can also be caused by chronic hepatitis B and C viral diseases.

Hepatocellular carcinoma: This is also a possibility in this case presentation given the features of hepatic impairment as well as hepatomegaly (Asafo-Agyei & Samant, 2021). Additionally, his father died of liver cancer.

Probing Questions

  • How long have you had these symptoms?
  • How often do you drink? How many bottles of beer do you take per day?
  • Have you ever been convicted of driving while intoxicated?
  • Have you ever been diagnosed with hepatitis?
  • How often do you use medications such as acetaminophen?
  • How long do you bleed after an injury?

Plan

Diagnostics: Liver function tests, complete blood count, coagulation profile, serum C-reactive protein assay, Hepatitis B surface antigen, and Anti-hepatitis C virus detection, alpha-fetoprotein assay, liver ultrasound, liver CT and MRI, and liver biopsy.

Medications: Vitamin K parentally, supplemental vitamins including folate and thiamine. Glucocorticoids, Naltrexone and liver transplantation.

Patient education and follow-up instructions: BM should be instructed to stop alcohol, participate in regular exercises, and should be offered adequate nutrition and dietary support. BM should be followed up by a multidisciplinary team of healthcare professionals including an internist, neurologist, nephrologist, and nutritionist.

Upper Abdominal Pain Soap Note Sample References