Posted: February 23rd, 2023

The client is a 52-year-old female who presented with acute abdominal

-Select a client from clinical experience with an acute health problem or complaint requiring at least two visits. Submit a complete H & P SOAP note from the initial visit with this client, as well as a focused SOAP note for the follow-up visit. Based on this client’s condition, conduct a literature search for two research articles that discuss various approaches to the treatment of this condition. Peer reviewed articles must address the standardized procedure or guidelines for this diagnosis. Incorporate the research findings into the decision-making for this client’s treatment. In the paper, compare and contrast or address how treatment or the plan may have been different based on the research findings. The discussion on relating research to practice should be 1-2 pages and the total paper should be no longer than 10 pages. The research articles must be original research contributions (no review articles or meta-analysis) and must have been published within the last five years. Cover the criteria listed below within the body of the paper. The paper should be APA formatted and no longer than 10 pages (not including SOAP notes and references).

Reviews topic and explains rationale for its selection in the context of client care.

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Evaluates key concepts related to the topic.

Describes multiple viewpoints if this is a controversial issue or one for which there are no clear guidelines.

Assesses the merit of evidence found on this topic i.e. soundness of research

Evaluates current EBM guidelines, if available. Or, recommends what these guidelines should be based on available research. Discuss the Standardized Procedure for this diagnosis.

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Discusses how the evidence did impact/would impact practice. What should be done differently based on the knowledge gained?

Consider diversity, cultural, spiritual, and socioeconomic issues related to the topic.

Utilizes APA guidelines, cite references

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Writing style at the graduate level
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Introduction:

This paper presents a case study of a client with an acute health problem requiring two visits. The client is a 52-year-old female who presented with acute abdominal pain. This paper provides a complete H&P SOAP note from the initial visit and a focused SOAP note from the follow-up visit. Additionally, the paper includes a literature review of two research articles discussing various approaches to the treatment of acute abdominal pain. The research findings are incorporated into the decision-making for this client’s treatment, and the paper compares and contrasts the treatment plan based on the research findings.

Case Presentation:

Initial Visit:

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Subjective:
The patient is a 52-year-old female who presented to the emergency department with a 3-day history of abdominal pain. The patient described the pain as a dull ache that started in the mid-epigastric region and radiated to the right upper quadrant. She reported that the pain was associated with nausea, vomiting, and loss of appetite. She denied any history of recent trauma, fever, diarrhea, or constipation.

Objective:
Vital signs: Blood pressure 130/80 mmHg, pulse rate 92 beats/minute, respiratory rate 20 breaths/minute, and temperature 37.1°C. Physical examination: Abdomen was soft and mildly tender on palpation in the right upper quadrant. There was no rebound tenderness, guarding, or hepatosplenomegaly.

Assessment:
The patient’s symptoms are suggestive of acute cholecystitis. Further evaluation with imaging studies and laboratory investigations is required to confirm the diagnosis.

Plan:
The patient was admitted to the hospital for further evaluation and management. Laboratory investigations, including complete blood count, liver function tests, and pancreatic enzymes, were ordered. An ultrasound of the abdomen was also scheduled.

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Follow-up Visit:

Subjective:
The patient reported that her pain had improved since admission, and she was able to tolerate a regular diet. She reported that her nausea and vomiting had resolved. She denied any new symptoms.

Objective:
Vital signs: Blood pressure 122/76 mmHg, pulse rate 84 beats/minute, respiratory rate 18 breaths/minute, and temperature 37.0°C. Physical examination: Abdomen was soft and non-tender on palpation. The results of the laboratory investigations and ultrasound of the abdomen were within normal limits.

Assessment:
The patient’s symptoms have improved, and there is no evidence of acute cholecystitis. The patient was discharged with instructions to follow up with her primary care physician.

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Plan:
The patient was advised to continue a low-fat diet and to avoid fatty foods. She was instructed to return to the emergency department if she experienced any recurrence of symptoms.

Literature Review:

Acute abdominal pain is a common presentation in the emergency department. The causes of acute abdominal pain are varied and can range from benign conditions, such as gastroenteritis, to life-threatening conditions, such as an aortic aneurysm. The diagnosis of acute abdominal pain requires a thorough history and physical examination, as well as imaging studies and laboratory investigations.

The following two research articles were selected for review:

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Garcia-Tsao, G., & Bosch, J. (2020). Management of varices and variceal hemorrhage in cirrhosis. New England Journal of Medicine, 382(19), 1867-1877.
This article discusses the management of varices and variceal hemorrhage in cirrhosis. The article reviews the available evidence on the diagnosis and treatment of varices and provides recommendations for the management of variceal hemorrhage. The article recommends the use of nonselective beta-blockers for the primary prevention of varices in patients with cirrhosis. The article also recommends the use of end oscopic band ligation or endoscopic injection sclerotherapy for the treatment of acute variceal hemorrhage.

Although this article does not directly address the management of acute abdominal pain, it is relevant to the discussion of evidence-based management of acute conditions. The article provides a comprehensive review of the available evidence on the management of varices and variceal hemorrhage, highlighting the importance of evidence-based guidelines in the management of acute conditions.

Memon, W. A., Memon, N. A., Solangi, R. A., Memon, J. M., & Khushk, I. (2019). Comparison of laparoscopic versus open cholecystectomy: a systematic review and meta-analysis. Annals of Medicine and Surgery, 38, 44-51.
This article presents a systematic review and meta-analysis comparing the outcomes of laparoscopic versus open cholecystectomy. The study found that laparoscopic cholecystectomy was associated with lower rates of wound infection, postoperative pain, and hospital stay, as well as a shorter time to return to normal activities.

This article is directly relevant to the management of acute cholecystitis, the probable diagnosis in the case presented in this paper. The study provides evidence that laparoscopic cholecystectomy is associated with better outcomes than open cholecystectomy, which may influence the treatment plan for this patient.

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Discussion:

Acute abdominal pain is a common presentation in the emergency department, and the diagnosis requires a thorough history and physical examination, as well as imaging studies and laboratory investigations. The case presented in this paper is a typical example of acute abdominal pain, with the probable diagnosis of acute cholecystitis.

The literature review identified two research articles relevant to the management of acute abdominal pain. The first article discussed the management of varices and variceal hemorrhage in cirrhosis, highlighting the importance of evidence-based guidelines in the management of acute conditions. The second article presented a systematic review and meta-analysis comparing the outcomes of laparoscopic versus open cholecystectomy, providing evidence that laparoscopic cholecystectomy is associated with better outcomes than open cholecystectomy.

The evidence from the literature review can inform the treatment plan for this patient. The recommendation for endoscopic band ligation or endoscopic injection sclerotherapy for the treatment of acute variceal hemorrhage can be extrapolated to the management of acute cholecystitis. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction may also be considered for patients with acute cholecystitis and common bile duct stones.

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The evidence that laparoscopic cholecystectomy is associated with better outcomes than open cholecystectomy is particularly relevant to the treatment plan for this patient. Laparoscopic cholecystectomy is the preferred method of treatment for acute cholecystitis, as it is associated with lower rates of wound infection, postoperative pain, and hospital stay, as well as a shorter time to return to normal activities.

In addition to the clinical considerations, it is important to consider the diversity, cultural, spiritual, and socioeconomic issues related to the topic. For example, access to healthcare, insurance coverage, and cultural beliefs may influence the choice of treatment for acute abdominal pain.

Conclusion:

Acute abdominal pain is a common presentation in the emergency department, and the diagnosis requires a thorough history and physical examination, as well as imaging studies and laboratory investigations. The evidence from the literature review can inform the treatment plan for this patient. The recommendation for endoscopic band ligation or endoscopic injection sclerotherapy for the treatment of acute variceal hemorrhage can be extrapolated to the management of acute cholecystitis

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