Hi. I am doing a SOAP Note for a patient with Acute Pancreatitis....

Question Answered step-by-step Hi. I am doing a SOAP Note for a patient with Acute Pancreatitis…. Hi. I am doing a SOAP Note for a patient with Acute Pancreatitis. Could you please check my plan and diagnosis? This visit is at a doctor’s office. Is there anything else the doctor should do (labs, medications, etc) before sending the patient to the hospital? Is the diagnostic test correct?History of Present Illness (HPI): Mrs. Y. S is a 45-year-old Hispanic female who presents to the with abdominal pain. Four hours prior, the patient had acute, sharp, epigastric pain, 8/10 in severity, radiating to the back while ironing, which is slightly relieve by sitting forward. The exacerbating pain factors include bending and lying down. She reports general body weakness. Patient suffered nausea and vomiting twice during the assessment session.Current Medications: Patient was not under any medication at the time of the visit.Allergies: No known allergies reported. Past Medical History (PMHx): Patient received last Tdap vaccine five years ago after suffering an injury. She states she received rehabilitation care 3 years ago and has recovered. No other significant disorders. The patient has never been hospitalized. No surgeries are reported.A. Diagnostic Tests: A computed tomography (CT) abdomen scan was done to rule out the differential diagnosis and to help with the identification of early pancreatic tissue death.Diagnostic Results: The diagnostic results include inflammation of the upper abdomen and delayed gastric emptying.Primary diagnosis:Acute pancreatitis:This condition is characterized by symptoms that include inflammation of the pancreas that occurs swiftly (Gapp & Chandra, 2020). The key symptom is upper abdominal pain and tenderness, and the pain may radiate to the back: fever, nausea and vomiting, and general body weakness. A contributing element is increased alcohol intake. These symptoms and signs are prevalent in Mrs. Y. S. Also, the CT abdominal scan confirms inflammation of the upper abdomen. Lastly, the patient takes alcohol each weekend, a key contributing aspect to acute pancreatitis. Differential diagnosis: Acute cholecystitisAcute cholecystitis is a condition that is caused by gall bladder inflammation, with the primary cause being cystic duct obstruction. It is characterized by a mass on the right upper quadrant, fever, right upper quadrant pain and tenderness, and a positive Murphy’s sign (Schuld & Glanemann., 2015). However, for this patient, no masses are noted on palpation ruling out this differential diagnosis. Peptic ulcer diseaseThis is an epigastric condition characterized by painful sores or ulcers that develop in the lining of the stomach or duodenum. The ulcers that develop in the gastroduodenal mucosa cause stomach pain and often lead to gastrointestinal (GI) bleeding (Dunlap & Patterson, 2019). The condition can also be described as ulcerative disorders that affect the lower stomach, lower esophagus, and upper duodenum. Risk factors for peptic ulcer disease (PUD) include smoking, frequent use of anti-inflammatory drugs, and regularly drinking alcohol (Dunlap & Patterson, 2019). Common symptoms include upper abdominal pain, fatigue, and abdominal discomfort. The subjective and objective indicates presence of PUD, but a CT abdomen scan rules out PUD because the patient’s upper abdomen is inflamed, and inflammation on the upper abdomen is not a symptom of PUD. P. The patient care plan includes hospital admission enabling treating of dehydration through intravenous (IV) fluids and short-term liquid feeding to prevent constipation. As the body devotes fluids and energy to repair the pancreas, the patient may experience dehydration, and intravenous (IV) fluid is critical in remaining hydrated (Goodchild et al., 2019). After the hospital admission, the provider will administer 2 grams IV of Ampicillin every 6 hours a day to act as an antibiotic for a period of three weeks. The provider will also administer 50 mg PO of Demerol daily every 4 hours as needed for three weeks for pain management. Moreover, the doctor will prescribe 666 mg PO of Acamprosate three times a day for three weeks to reduce alcohol dependency symptoms. The side effects of the above medications include rashes, nausea, vomiting, loss of appetite, drowsiness, confusion, and mood changes. The provider will educate Mrs. Y.S about the dangers of continued alcohol-intake to her health status. The doctor should also educate the patient about the best diet during the recovery period, that is, a low-fat diet. The doctor should recommend that the patient tries counseling, self-help groups, and therapy. The patient should continuously monitor depression and suicidal symptoms, and her pancreatic levels. She should return to the primary care doctor three weeks after release from admission for him to check her progress and observe any presenting symptoms. Health Science Science Nursing NRNP 6531 Share QuestionEmailCopy link Comments (0)