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The note’s list of subjective data thoroughly reviews the patient’s symptoms, previous medical history, current medicines, and allergies. The presence of nausea, the overall length of symptoms, the precise location of pain, changes in bowel movements, the frequency of dizziness or sweating after meals, the amount of activity impacted by abdominal pain, recent weight changes, the use of over-the-counter medications or herbs, previous abdominal problems, history of any recent abdominal surgery, small bowel obstruction, or gallbladder problems are all additional details that should be recorded in the documentation.
Analysis of the Objective Portion of the Note and Additional Information
The note’s objective section includes a summary of the patient’s vital signs and the results of the physical examination of the heart, lungs, skin, and abdomen. The physical exam’s paperwork should also include specific localizing symptoms like abdominal stiffness, rebound soreness, or pain worsening with breathing. Note should also be taken of any hernias, distensions, masses, organomegaly, guarding, costovertebral angle pain, fluctuation, and other conditions.
Why the Subjective and Objective Information Fails to Support the Assessment
The evaluation of abdominal aortic aneurysm, perforated ulcer, and pancreatitis lacks substantiation based on the subjective and objective data presented in the note. The patient’s primary concern regarding the manifestation of epigastric abdominal pain for a duration of two days, with subsequent radiation into the back, does not align with any of the diagnoses above. It is worth noting that abdominal aneurysms and pancreatitis typically induce a gradual onset of abdominal pain over an extended period, spanning multiple days. Conversely, perforated ulcers commonly present with acute and intense abdominal pain. These observations are supported by the scholarly works of Mohy-ud-din and Morrissey (2019), Shaw et al. (2020), and Stern et al. (2020). Furthermore, the lack of tangible physical examination manifestations suggestive of abdominal aortic aneurysm or pancreatitis further undermines the credibility of the diagnoses above.