Week 3 dq 1

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  1. Access the DxR Clinician website at https://gcu.dxrclinician.com/.
  2. Select the folder labeled: ANP_654.
  3. Select the Tommy Jackson – Abdominal Pain case study.
  4. Upon clicking on the case, you will see the “Enter Case” button at the top of the page. Select “Enter Page.” Under “Name,” enter First Initial, Last Name, all in lower case. Leave password blank. This will give you entry into the case study.
  5. Complete the Tommy Jackson – Abdominal Pain case.
  6. Discuss the diagnostic tool you selected and explain how it was helpful. Remember that pertinent negatives also guide your diagnoses. Describe how you prioritized the data.

Support your summary and recommendations plan with a minimum of two APRN approved scholarly resources.

SOAP NOTE

SUBJECTIVE (S)

Patient Name: Tommy Jackson
Age: 18
DOB: unknown
Sex: Male
Date of Visit: January 24, 2022

Chief Complaint:
“I have this horrible pain in my belly”

History of Present Illness (HPI):
This is an 18-year-old Caucasian male that presents with abdominal pain that started about 5
hours ago while playing tennis. Patient indicates the pain is located in his lower right side and
feels like “burning and a cramp at the same time”. Patient believed it was a pulled muscle but
after sitting down to rest, the pain did not go away. Patient states the pain is worse if he tries to
“straighten up” and pain feels better when “bent forward”. Patient describes the pain as “the
worst pain I ever had.” Pain is continuous and does not radiate. Patient reports associated
nausea. Patient indicates he drank 7up soda which made him feel worse. No other treatments
were tried. Patient denies vomiting, diarrhea, and fever.

Past Medical History (PMH):
Childhood Illnesses: None
Adult Illnesses: None
Medical: None
Surgical: Rhinoplasty 1/23/2022
Allergies: NKDA
Current Medications: Cephalexin 500mg BID PO daily (duration unknown, started
yesterday); Acetaminophen and Codeine PRN for pain (dose, frequency, and
duration unknown; for post-op ENT surgery pain); Acetaminophen PRN for headaches
(dose and frequency unknown)
Health Maintenance, Immunizations, Exercise: unknown if patient has PCP; up to date
on all immunizations; exercises 3 days a week for 2 hours.
Family History: None
Psychosocial History: Tommy is a senior in high school. He lives at home with his parents
and two older brothers. States he “lives in a nice house in a good part of town”. He
works at McDonalds on Saturdays and enjoys exercise and hanging out with his friends.
He drives his mom car when he needs to go somewhere. He denies alcohol use, tobacco
use, and illicit drug use. Tommy is sexually active. He denies any hospitalizations,
psychiatric conditions, or suicidal ideations.
Diet: Patient drinks 1 cup of coffee in the morning and about 3-4 colas during the day.
Patient states “I eat healthy”.

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ROS
Constitutional: Denies any weight changes. Denies weakness and fever. Denies changes in
mental capacity. Denies changes in sleeping pattern.
Skin: Denies redness, swelling, rashes, and itching. Denies hair loss or changes. Denies changes
in nails. Denies sores and bruises.
Head: Reports headaches every once in a while. Denies masses or growths. Denies head
trauma.
Eyes: Denies eye pain, redness, and drainage. Denies visual loss, double vision, and ptosis.
Ears: Denies earaches, drainage, hearing loss, tinnitus, vertigo, and infection.
Nose: Reports congestion prior to rhinoplasty surgery. Reports tenderness post-surgery. Denies
drainage, and itching. Denies epistaxis.
Throat: Denies throat soreness. Denies mouth pain, dryness, and oral ulcers. Denies taste
problems.
Neck: Denies pain or swelling
Respiratory: Denies cough, shortness of breath, and wheezing. Denies hemoptysis and chest
pain. Denies lung diseases and infections.
Cardiovascular: Denies chest pain, palpitations and murmurs. Denies peripheral edema and
claudication. No history of cardiac exams or conditions.
Gastrointestinal: Denies diarrhea, constipation. Reports regular bowel movements daily. Denies
difficulty swallowing, heartburn, and hematemesis. Reports RLQ abdominal pain. Reports no
appetite today. Denies rectal bleeding, discharge and pain. Denies black, tarry stools. Reports
nausea. Denies past GI disorders.
Genitourinary: Denies frequency, urgency, burning, and pain during urination. Denies
hematuria. Denies STDs. Reports being sexually active.
Musculoskeletal: Denies fractures, sprains, and dislocations. Denies muscle soreness, cramps,
stiffness, and twitching. Denies back pain. Denies muscle weakness and strength loss.
Neurological: Denies changes in speech, memory, and attention. Denies numbness, weakness,
visual problems.
Psychiatric: Denies personality or behavior changes. Reports feeling anxious about abdominal
pain. Denies depression. Denies alcohol and substance abuse. Denies suicidal thoughts.
Endocrine: Denies excessive hunger and thirst. Denies fatigue, weight loss, and weight gain.
Denies increase in urination.

OBJECTIVE (O)
Vitals:
BP: 120/70
HR: 72 and regular
RR: 16 and regular
Temp: 98.6 orally
Weight: 140 lbs/63.5 kg
Height: 5’7” / 170.2cm
BMI: 22

Physical Exam:

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General: The patient is well groomed and dressed appropriately. The patient is alert and
oriented to person, place, time and situation. Answers questions appropriately.
HEENT: Normocephalic. Hair distribution is full; hair is thick, with good luster. The patient’s scalp
is smooth and supple; no lumps, interruptions, or other lesions are noted; the size and contour
are normal, without apparent deformities, and there are no areas of tenderness. Temporal
arteries soft, non-tender with no bruits. Auricles are symmetric, normally placed, and without
deformities; no area of tenderness is noted. No ear lobe creases are present. Bilateral tympanic
membranes are pearly gray with good cone of light, no erythema/bulging or retraction noted;
bilateral, boney landmarks are visible. Eyes are symmetric in size, shape, color, and position. No
scars, erythema, or growths are noted on lid or conjunctiva. Cornea is clear; pupils are equal,
round, and reactive to light accommodation. Sclerae anicteric, conjunctiva pink/moist and
without drainage. Nose shows evidence of recent surgery with swelling. Nares are patent
bilaterally. Twenty-six teeth are present, with no cavities, and no active caries are noted; teeth
are well-aligned and occlusion is symmetric with slight overbite. Gums are pale red and meet
enamel margins of the teeth. Lips appear normal without ulcers or cracking. Buccal mucosa is
pink, moist, and without ulcers or nodules. Hard palate is midline and moves symmetrically.
Tongue appears normal without coating. Pharynx and tonsils appear normal without exudate.
NECK: Supple. No cervical lymphadenopathy. No thyromegaly or jugular vein distention.
RESPIRATORY: Respirations are unlabored, symmetrical chest wall expansion, no chest wall
tenderness. Lung sounds clear. No cyanosis or clubbing of the fingers.
CARDIOVASCULAR: The heart has a regular rate and rhythm, no gallops, rubs, or murmurs. S1 &
S2 normal. No thrills or bruits are present. No edema of the lower extremities.
MUSCULOSKELETAL: Active range of motion of the joints. No lumbar tenderness. There is
paraspinal muscle spasm noted from T12 to L1.
GASTROINTESTINAL: Abdomen is soft. There is tenderness in the RLQ on light palpation and
severe pain on deep palpation. No masses can be palpated. Questionable rebound tenderness
present. No pain on palpation of LLQ or LUQ; slight referred pain to the RLQ. There is
tenderness on deep palpation in the RUQ at the tip of the 12th rib and a positive Chapman’s
reflex at that point. The gallbladder is not palpable. The liver edge is palpable on deep
inspiration; it is smooth and non-tender. There is slight referred pain to the RLQ on deep
palpation. There is no rebound tenderness. Active bowel sounds in all quadrants.
INTEGUMENTARY: Skin is pink, warm and dry. No rash present.
NEUROLOGIC: Normal comprehension, fluency. Normal strength, bulk and tone in muscles of
extremities. Alert and oriented.
PROSTATE/RECTAL: The sacrococcygeal area is free of sinus tracts and the perianal area is free
of rashes, excoriations, or other lesions; no external hemorrhoids are present; the anal
sphincter has good tone; examination produces minimal discomfort; no internal hemorrhoids,
irregularities or nodules are palpated; a small amount of soft stool is present in the rectum. The
prostate is smooth, symmetric, and not enlarged; there are no nodules or areas of induration,
and it is non-tender. Upon straining, no descending lesions are palpable.

Testing:

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1. CBC w/dif: WBC 17.9, RBC 5.3, Hemoglobin 15.2, Hematocrit 46.6%, MCV 85, MCH 32,
MCHC 34.0%, Platelets 356, Bands 0%, Neutrophils 66%, Lymphocytes 28%, Eosinophils
2%, Monocytes 3%, Basophils 1%

2. CRP: 0.8 mg/dL
3. Creatinine: 0.9 mg/dL
4. Urinalysis, Routine: pH 6.5, Specific Gravity 1.020, Protein none detected, Bilirubin none

detected, Glucose none detected, Ketones none, Occult Blood none, RBCs/HPF 2/3,
WBCs/HPF 0/1, Bacteria none, Epithelial Cells 0/1, Casts none, Nitrates negative,
Urobilinogen negative

5. CT Abdomen: sigmoid colon, bladder, and ureters are normal in appearance. However,
the cecum is enlarged and there is a small fluid collection

6. Ultrasound Abdomen: No hepatosplenomegaly noted, gallbladder within normal limits
as is the common bile duct, no masses or abnormal fluid collections

ASSESSMENT (A)

Diagnosis
New problems: RLQ abdominal pain, nausea
Primary Diagnosis: Acute appendicitis ICD-10 K35
Diferentials:

1. Noninfective gastroenteritis and colitis, unspecified ICD-10 K52.9
2. Calculus of kidney ICD-10 N20.0
3. Diverticulitis of intestine, part unspecified, without perforation or abscess without

bleeding ICD-10 K57.92
PLAN (P)

Treatment: Consult General Surgery for appendectomy. Patient to remain NPO. PRN analgesics
and antiemetics for pain and nausea (Toradol and Zofran). Ensure peripheral IV is inserted.
Initiate IV fluids and systemic antibiotics (defer choice in ABX to surgery).

Education: Patient educated on appendectomy surgery; made aware of risks and complications
associated with surgery. Instructed to avoid strenuous activities until cleared by surgeon. Keep
incisions clean and dry. Eat a bland, low-fat diet. Further education/questions directed to the
surgery team.

Follow-up: as needed basis. Should follow-up with surgery team 2-3 weeks post-op. Follow
up/call healthcare provider sooner with any of the following: swelling, pain, fluid, or redness in
the incision that gets worse; fever of 100.4 or higher; abdominal pain that gets worse; severe
diarrhea, bloating, or constipation; nausea or vomiting; trouble breathing or shortness of
breath; leg swelling.

Patient verbalized understanding of the treatment plan and education provided.

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Tommy Jackson is an 18-year-old male who presents with acute abdominal pain that began while playing tennis about five hours ago. He describes it as a burning pain in his lower right abdomen without radiation. He has associated anorexia and nausea without vomiting. He also denies any recent injury, but had nasoseptal repair surgery yesterday. He denies chronic medication use, but was started on prophylactic Keflex and PRN Tylenol-codeine by his ENT surgeon.   

Upon exam, his right abdomen is tender to palpation and palpation of the left lower quadrant produces pain in the right lower quadrant (positive Rovsing’s sign) (Krzyzak & Mulrooney, 2020).  He reports pain relief with learning forward and worsening with lying flat. On auscultation he has active bowel sounds without bruits. My differentials were: acute appendicitis, cholecystitis (low suspicion), diverticulitis, bowel perforation, kidney stones, and bowel obstruction. I began the work up with a CBC that demonstrated leukocytosis with a left shift. This is consistent with many infectious abdominal pathologies. I elected to do an abdominal ultrasound to evaluate for acute appendicitis and cholecystitis, which was unremarkable. I then decided to order an abdominal CT; that demonstrated an enlarged cecum with fluid collection which is consistent with acute appendicitis. A diagnosis of appendicitis can be made with right lower quadrant pain and a visualized appendix >6mm in diameter (Krzyzak & Mulrooney, 2020). After research, I discovered an abdominal ultrasound is often nondiagnostic in acute appendicitis and abdominal CT is preferred (Cappell, 2017, p. 3074). The positive predictive value of a CT in appendicitis is 95-97% with an accuracy of 90-98%  (Cappell, 2017, p. 3074). However, some literature does suggest beginning with an abdominal ultrasound as it is less risky and more cost-effective to the patient and escalating to a CT if the US is nondiagnostic. Although, an ultrasound is more sensitive and specific in children with appendicitis (Cappell, 2017, p. 3074).  

References

Cappell, M. S. (2017). Large bowel disorders. In Principles and practice of hospital medicine (2nd ed., pp. 3051–3090). McGraw Hill.

Krzyzak, M., & Mulrooney, S. M. (2020). Acute appendicitis review: Background, epidemiology, diagnosis, and treatment. Cureus12(6). 
https://doi.org/10.7759/cureus.8562

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