ABDOMINAL ASSESSMENT

write 3 pages of SOAP note with 5 to 6 sources on the following case study. 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-day history of intermittent epigastric abdominal pain that radiates into his back. He went to the local Urgent Care where was given PPIs 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 PLAN: