Advances in Management of Acalculous Cholecystitis Discussion Paper

Soap Note Analysis

Subjective Portion Analysis

In the subjective part of the note, there is a dearth of vital information that contributes to an appropriate diagnosis. As such, additional information that should be included includes:

• Characteristics the pain
• Severity of the pain
• Whether it is constant or progressive pain
• What relieves or aggravates the pain
• Whether any medication has been taken within the past week
  

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Objective Portion Analysis

There are critical things missing from the soap note when it comes to the objective information. Additional information that should be included in this section includes:

• Overall appearance of the patient
• Patient’s level of consciousness
• Findings of any laboratory tests performed
• Color of the patient’s skin Advances in Management of Acalculous Cholecystitis Discussion Paper

Is the assessment supported by subjective and objective information?

Both the subjective and the objective facts provide credence to the assessment. The patient has a history of experiencing stomach discomfort that has gradually become worse over time, along with vomiting. In addition, he expresses discomfort in the epigastric area as well as guarding, all of which are consistent with the presence of abdominal pain.

 Appropriate Diagnostic Tests

Diagnostic tests that will be required for this patient include:

• Complete blood count- to determine the presence of infection and bleeding,
• Chest/abdominal X-ray- to check for perforated ulcer.
• Abdominal ultrasonography- to determine the presence of abdominal aortic aneurysms, perforated ulcers, and other abdominal issues
• Amylase and lipase tests- to determine the presence of pancreatitis
• Abdominal CT scan- to check for abnormalities in the abdominal region

 Reject/Accept the Current Diagnosis

The diagnosis of acute pancreatitis is reasonable to me; however the diagnoses of abdominal aortic aneurysm and perforated ulcer are not. Discomfort in the abdominal region, leg pain, and a pulsing abdomen are the signs of an abdominal aortic aneurysm, none of which are present in patient LZ. On the other hand, it is not possible for a perforated ulcer to cause discomfort in the back. Advances in Management of Acalculous Cholecystitis Discussion Paper

Three Possible Conditions

• Acute Pancreatitis:The quick onset of pancreatic inflammation is what’s meant to be understood by the term “acute pancreatitis” (Mederos et al., 2021). Abdominal discomfort is the most typical symptom of the condition.
• Gastritis: The term “gastritis” may apply to a number of different conditions, all of which are characterized by inflammation of the lining of the stomach (Azer et al., 2019). Vomiting, nausea, and upper stomach discomfort are among the symptoms of this condition.
• Cholecystitis:Cholecystitis is an inflammation of the gallbladder, which may be caused by a number of different conditions. This illness may manifest itself in a variety of ways, including discomfort in the right upper abdomen region, soreness in the right shoulder, vomiting, and nausea (Balmadrid, 2018). Advances in Management of Acalculous Cholecystitis Discussion Paper

References

Azer, S. A., & Akhondi, H. (2019). Gastritis. https://europepmc.org/article/nbk/nbk544250

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2017). Seidel’s Guide to

Balmadrid, B. (2018). Recent advances in management of acalculous cholecystitis. F1000Research, 7, 1660. https://doi.org/10.12688/f1000research.14886.1

 Mederos, M. A., Reber, H. A., & Girgis, M. D. (2021). Acute pancreatitis. JAMA, 325(4), 382 Advances in Management of Acalculous Cholecystitis Discussion Paper