Abdominal Pain: A SOAP Note Analysis

Abdominal Pain: A SOAP Note Analysis
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History and Physical Examination
History taking and complete physical examination are highly significant in discerning a proper diagnosis. Furthermore, these elements are significant in considering the differential diagnosis (Battaglia, D’Angelo, & Kettner, 2016). In this narrative, the provided case will be analyzed to supplement additional information to be able to generate a complete history and physical examination findings. 
Subjective
HPI
           The HPI should be evaluated every day until the patient’s visit to the hospital. This everyday narrative must include the onset and quality of pain, aggravating and relieving factors, location and radiation, and duration (Gans, Pols, Stoker, Boermeester, & Expert Steering Group, 2015). The location is of an utmost priority since there are specific organs located in each abdominal quadrant. It is also significant in identifying the probability of a referred pain (Access Medicine, n.d.).
Additionally, the food that the patient eats, bowel movement, and hydration status must be evaluated. The type of food and bowel movement, as well as the quality, smell, and color of the stool, are important in evaluating an acute abdomen because these can give clues on whether the disease is bacterial, viral, or parasitic in origin. It can also verify other diseases like acute pancreatitis such when eating fatty foods, cholecystitis, etc (Bhangu, Søreide, Di Saverio, Assarsson, & Drake, 2015). Noteworthy negatives must also be included in the history. It was stated that the patient experienced nausea after eating. This data will be more helpful if vomiting is present or absent (Gans, Pols, Stoker, Boermeester, & Expert Steering Group, 2015).
Past Medical History
           The presence of previous surgeries must also be noted as this may rule in or rule out the presence of primary or metastatic tumors. 
Medications
The clinician must also assess the patient’s former medications as well as the duration these were taken. For example, non-steroidal anti-inflammatory drugs (NSAIDs) can cause ulceration of the stomach due to the inhibition of the cyclooxygenase (COX) pathways, namely COX-1 and COX-2, where the COX-1 pathway is gastroprotective (Scheiman, 2016).
Family History
           Other types of cancers that metastasize to the gastrointestinal tract (GIT) must also be noted. 
Social History
           The sanitation, hygiene, and source of drinking and bathing water must also be assessed because this may point out bacterial, viral, or parasitic causes of abdominal pain (Yusof et al, 2017). 
Objective
Anthropometric Measurement
           The body mass index (BMI) is calculated by the weight in kilograms (kg) over the height in meters squared (m2). The clinician only assessed the patient’s weight but not the height. BMI is important to determine obesity since obesity is also linked to some causes of the acute abdomen like pancreatitis ...