11285 - 4 Pages within 48 Hrs

Format: APA Pages: 4 pages ( 1100 words, Double spaced) Number of sources: 3 Academic level: Master's Subject or discipline: Nursing Title: Writer's choice Paper instructions: Please review attached file and write a SOAP note about diarrhea, pt data can be made up. Treatment: Consider stool testing for patients with high risk factors such as prolonged diarrhea, bloody diarrhea, recent antibiotic usage, travel. Antimotility agents are not indicated for true infectious diarrhea. Probiotics have been found to be useful and without side effects and diarrhea. Antibiotics are not generally recommended in adults with acute diarrhea. Wait for cultures if necessary. Loperamide (Imodium) 2 mg every 4 hours as needed for diarrhea. Avoid if bloody stools or with fevers. Diphenoxylate (Lomotil) is a another antimotility medication. High risk of side effects. Dose is 4 mg every 6 hours as needed for diarrhea. Bismuth subsalicylate can also be used sparingly for symptoms. History of Present Illness Patient presenting for evaluation of diarrhea, watery stools, abdominal discomfort. Onset of symptoms was 3 days ago. Patient describes a intermittent abdominal pain. Patient has associated symptoms of abdominal cramping, abd discomfort. Patient does not have symptoms of nausea, vomiting, fever, bloody stools, dark stools. Patient reports recent antibiotic usage, recent travel, no recent travel. Patient has no sick contacts. Aggravating symptoms include nothing. Treatment prior to arrival includes Pepto-Bismol, imodium. Review of Systems: All other systems reviewed and are negative Physical Exam: Constitutional: No acute distress HEENT: Head normocephalic and atraumatic. CV: Regular rate and rhythm. No murmur. Respiratory: Lungs clear to auscultation bilaterally Extremities: Non-tender. No pedal edema. Back: No tenderness Neuro: No gross motor deficits Skin: Normal color. Warm and Dry Abdomen: soft, nontender, bowel sounds hyperactive, distended, no rebound or guarding Past Medical History: hypertension, hyperlipidemia, hypothyroidism, COPD Past Surgical History: hysterectomy Social History: tobacco use Family History: no pertinent family history Medical Decision Making Patient presenting with diarrhea. No evidence of acute surgical emergency or infection requiring antibiotics. Diagnostic testing performed: stool testing obtained and pending. Treatments provided included oral hydration, imodium. Patient prescribed Lomotil. Pt was advised on supportive therapies, including increasing dietary fiber, eating smaller meals, refrain from eating copious amounts of irritating foods (fatty foods, milk products, chocolate, and caffeine), maintaining a food diary, advancing fluids as tolerated, refraining from EtOH consumption, decreasing stress, and increasing exercise. Maintain Fluid Intake: Pedialyte/Gatorade, Juice, Non-caffenated Pop (Sprite, 7-Up). Clear liquid diet, advance as tolerated. Patient is to followup with primary physician if having continued symptoms. Advised to return to the ER if concern for inability to tolerate PO intake, dehydration, bloody stools, or other concerns.