week 6 paper
rosario08
SOAPassessabdominalpain20201.docx
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
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Initials: E.P. |
Age: 78 years old |
Gender: Female |
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Height |
Weight |
BP |
HR |
RR |
Temp |
SPO2 |
Pain Rating |
Allergies (and reaction) Latex ( skin rash) |
| 5’ 2 feet | 120 lbs | 110/70 | 92 | 16 | 37.0 | 99 % |
6/10 |
Medication: NKA Food: NKA Environment: latex (dermatitis) |
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History of Present Illness (HPI) |
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Chief Complaint (CC) | Abdominal Pain |
CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom |
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O nset | Since 5 days ago |
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L ocation | Lower abdomen quadrants |
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D uration | 5 days ago |
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C haracteristics | Cramp, dull, discomfort |
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Aggravating factors | Activity and eating |
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R elieving Factors | Rest and not to move too much |
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T reatment | Click or tap here to enter text. |
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Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. |
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Medication (Rx, OTC, or Homeopathic) |
Dosage |
Frequency |
Length of Time Used |
Reason for Use |
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| Accupril PO | 10 mg | daily | continue | HTN | ||||
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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
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Hypertension diagnosed at age 54 Immunizations up to the date No flu vaccination this year (pending for next appointment) 3 pregnancies Surgical history of a C-section at 40 and a cholecystectomy at 42 No recent hospitalizations. |
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Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. |
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Patient denied tobacco, cigar and marihuana Patient denied any use of any illicit drugs Pt drink one glass of dry wine sometimes
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Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. |
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Mother: history of hypertension and DM type II. Father: Died in his sleep, history of hypertension and hypercholesterolemia. Maternal grandparents: family history of coronary artery disease and DM type II. Paternal grandparent’s family history of obesity, CVA and hypertension. Siblings: HTN, hypercholesterolemia, prostate cancer (one of the brother). Son and daughter with no medical history.
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Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. |
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Constitutional If patient denies all symptoms for this system, check here: ☐ |
Skin If patient denies all symptoms for this system, check here: ☐ |
HEENT If patient denies all symptoms for this system, check here: ☒ |
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☒Fatigue Click or tap here to enter text. ☐Weakness Click or tap here to enter text. ☐Fever/Chills Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☐Trouble Sleeping Click or tap here to enter text. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. |
☐Itching Click or tap here to enter text. ☐Rashes Click or tap here to enter text. ☐Nail Changes Click or tap here to enter text. ☒Skin Color Changes flushed ☐Other: Click or tap here to enter text.
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☐Diplopia Click or tap here to enter text. ☐Eye Pain Click or tap here to enter text. ☐Eye redness Click or tap here to enter text. ☐Vision changes Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Eye discharge Click or tap here to enter text.
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☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text.
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☐Hoarseness Click or tap here to enter text. ☐Oral Ulcers Click or tap here to enter text. ☐Sore Throat Click or tap here to enter text. ☐Congestion Click or tap here to enter text. ☐Rhinorrhea Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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Respiratory If patient denies all symptoms for this system, check here: ☒ |
Neuro If patient denies all symptoms for this system, check here: ☒ |
Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: ☒ |
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☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Sputum Production Choose an item. Choose an item. Choose an item. ☐Other: Click or tap here to enter text.
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☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. ☐Exercise Intolerance Click or tap here to enter text. ☐Orthopnea Click or tap here to enter text. ☐Edema Click or tap here to enter text. ☐Murmurs Click or tap here to enter text.
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☐Palpitations Click or tap here to enter text. ☐Faintness Click or tap here to enter text. ☐Claudications Click or tap here to enter text. ☐PND Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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MSK If patient denies all symptoms for this system, check here: ☒
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GI If patient denies all symptoms for this system, check here: ☐ |
GU If patient denies all symptoms for this system, check here: ☒ |
PSYCH If patient denies all symptoms for this system, check here: ☒ |
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☐Pain Click or tap here to enter text. ☐Stiffness Click or tap here to enter text. ☐Crepitus Click or tap here to enter text. ☐Swelling Click or tap here to enter text. ☐Limited ROM Choose an item. ☐Redness Click or tap here to enter text. ☐Misalignment Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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☐Nausea/Vomiting Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Blood in Stool Click or tap here to enter text. ☒Abdominal Pain Click or tap here to enter text. ☐Excessive Flatus Click or tap here to enter text. ☐Food Intolerance Click or tap here to enter text. ☐Rectal Bleeding Click or tap here to enter text. ☒Other: loose and watery stools 5 days ago, bloating, passing gases, distention and tenderness.
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☐Urgency Click or tap here to enter text. ☐Dysuria Click or tap here to enter text. ☐Burning Click or tap here to enter text. ☐Hematuria Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text.
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☐Stress Click or tap here to enter text. ☐Anxiety Click or tap here to enter text. ☐Depression Click or tap here to enter text. ☐Suicidal/Homicidal Ideation Click or tap here to enter text. ☐Memory Deficits Click or tap here to enter text. ☐Mood Changes Click or tap here to enter text. ☐Trouble Concentrating Click or tap here to enter text. ☐Other: Click or tap here to enter text. |
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GYN If patient denies all symptoms for this system, check here: ☒ |
Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒ |
Endocrine If patient denies all symptoms for this system, check here: ☒ |
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☐Rash Click or tap here to enter text. ☐Discharge Click or tap here to enter text. ☐Itching Click or tap here to enter text. ☐Irregular Menses Click or tap here to enter text. ☐Dysmenorrhea Click or tap here to enter text. ☐Foul Odor Click or tap here to enter text. ☐Amenorrhea Click or tap here to enter text. ☐LMP: Click or tap here to enter text. ☐Contraception Click or tap here to enter text.
☐Other:Click or tap here to enter text.
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☐Anemia Click or tap here to enter text. ☐ Easy bruising/bleeding Click or tap here to enter text. ☐ Past Transfusions Click or tap here to enter text. ☐ Enlarged/Tender lymph node(s) Click or tap here to enter text. ☐ Blood or lymph disorder Click or tap here to enter text. ☐ Other Click or tap here to enter text.
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☐ Abnormal growth Click or tap here to enter text. ☐ Increased appetite Click or tap here to enter text. ☐ Increased thirst Click or tap here to enter text. ☐ Thyroid disorder Click or tap here to enter text. ☐ Heat/cold intolerance Click or tap here to enter text. ☐ Excessive sweating Click or tap here to enter text. ☐ Diabetes Click or tap here to enter text. ☐ Other Click or tap here to enter text.
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O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Pertinent positive are the “abnormal” findings and pertinent “negative” are the expected normal findings. Separate the assessment findings accordingly and be detailed.
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Body System |
Positive Findings
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Negative Findings |
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General
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Click or tap here to enter text. |
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Skin
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Flushed of the skin noted during inspection |
Skin is warm, dry, clean and intact, no open wounds, no ulcerations, and no tenting, nasal mucosa and mouth are pink and moist |
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HEENT
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Click or tap here to enter text.
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No visible findings to the head, skull and facial symmetry, Nose and oral mucosa moist and pink. |
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Respiratory
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Click or tap here to enter text. |
Breath sounds present and clear in all the quadrants anteriorly and posteriorly, no adventitious sounds present |
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Neuro
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Click or tap here to enter text. |
Patient is alert and oriented x 4, follow commands, answer questions properly. |
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Cardiovascular
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Click or tap here to enter text. |
Heart sounds S1 and S2 audible in auscultation No additional heart sounds found |
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Musculoskeletal
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Click or tap here to enter text. |
Normal range of motion in all extremities, no stiffness noted |
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Gastrointestinal
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Distention, pain, tenderness and mass in left lower quadrant |
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Genitourinary
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Click or tap here to enter text. |
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Psychiatric
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Click or tap here to enter text. |
Pt denied any suicidal thoughts and denied any depression and anxiety. |
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Gynecological
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Click or tap here to enter text. |
No abnormal findings, no inflammation, no irritation, no discharges, no bleedings, no tenderness. Digital rectal exam: negative for hemorrhoids, no fissure or ulcerations, strong sphincter tome, no fecal mass detected |
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Problem List |
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| Constipation |
6. Click or tap here to enter text. |
11. Click or tap here to enter text. |
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2. Diverticulitis |
7. Click or tap here to enter text. |
12. Click or tap here to enter text. |
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3. Fecal or intestinal obstruction |
8. Click or tap here to enter text. |
13. Click or tap here to enter text. |
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4. Dehydration |
9. Click or tap here to enter text. |
14. Click or tap here to enter text. |
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5. Electrolyte Imbalance |
10. Click or tap here to enter text. |
15. Click or tap here to enter text. |
A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses (DDx) which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis.
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Diagnosis |
ICD-10 Code |
Pertinent Findings |
| Diverticulitis | K57.92 | Constant pain that last several days. Skin is flushed which can indicated that pt may start having a low grade fever, no BM in the last 5 days, last BM was watery with loose stools. |
| Intestinal Obstruction or Fecal Impaction Intra- abdominal Mass | K56. 41 R19.00 | Abdominal pain with cramps and colicky, vital signs may be normal in early bowel obstruction but with signs of dehydration ( acidic of the urine), abdominal distention and tenderness Mass and lump, swelling and bloating. |
| Dehydration | E 86.0 | Low fluid intake ( 2 glasses of water per day), skin is dry, and 6.5 urine acidity |
P: Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.
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Diagnostics: List tests you will order this visit |
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Test |
Rationale/Citation |
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| Ct scan of the abdomen | Is used to diagnose diseases of the small bowel, colon and other intestinal organs. It is painless and noninvasive and accurate to help to diagnose diverticulitis because it can show infected or inflamed pouches | ||
| X ray of the abdomen or KUB | It can help to diagnose fecal impaction because it can shows abdominal distention, bowel obstruction, or nonconstructive ileus and evaluation of palpable mass. | ||
| Chemistry 7 lab test | To check electrolytes imbalance and base line and kidney function | ||
| Click or tap here to enter text. | Click or tap here to enter text. | ||
| Click or tap here to enter text. | Click or tap here to enter text. | ||
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Medications: List medications/treatments including OTC drugs you will order and “continue meds” if pertinent. |
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Drug |
Dosage |
Length of Treatment |
Rationale/Citation |
| Accupril PO | 10 mg daily | Click or tap here to enter text. | HTN |
| Metronidazole | 500 by mouth BID | 14 days | Possible diverticulitis |
| Tylenol PO | 500 mg Q6 | PRN | For pain management |
| Senna PO | 8.6mg BID | daily | For constipation |
| Miralax 1 package | 1 package daily |
daily | For constipation |
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Referral/Consults: |
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Gastroenterologist |
Depending on CT or Xray diagnostic test results, a consult with specialist in GI is necessary to establish goals of care, management and continuity of care. | Click or tap here to enter text. | |
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Education: |
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Diet modification, increase in fluid intake, OTC fiber and continuity of active physical activity, pain management. |
Increase in fiber intake in diet is essential in case of fecal impaction and constipation. In addition, increase of fluid intake to 8 glasses of water per day is essential to prevent dehydration and constipation. Decreased the use of teas or herbal products because are diuretics (at least for now). Use of analgesic to control pain and symptoms. Use of stool softener to increase peristalsis. | Click or tap here to enter text. | |
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Follow Up: Indicate when patient should return to clinic and provide detailed symptomatology indicating if the patient should return sooner than scheduled or seek attention elsewhere. |
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Primary Care doctor follow up in 3 days Follow up with GI doctor
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To monitor improvement of symptoms , bowel sounds, bowel movement and monitor if medical treatment was effective | Click or tap here to enter text. | |
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References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct current APA edition formatting. |
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| Shin, A. (2020). Patient considerations in the management of chronic constipation: focus on prucalopride. Patient Preference and Adherence, 1373+. Retrieved from https://link.gale.com/apps/doc/A622160320/AONE?u=fjp_jvpl&sid=AONE&xid=6f22d865 Nigar, S., Sunkara, T., Culliford, A., & Gaduputi, V. (2017). Giant Fecalith Causing Near Intestinal Obstruction and Rectal Ischemia. Case Reports in Gastroenterology, 11(1), 59+. Retrieved from https://link.gale.com/apps/doc/A596061162/AONE?u=fjp_jvpl&sid=AONE&xid=31bb71f1 Pfutzer, R. H., & Kruis, W. (2015). Management of diverticular disease. Nature Reviews Gastroenterology & Hepatology, 12(11), 629+. Retrieved from https://link.gale.com/apps/doc/A434224977/AONE?u=fjp_jvpl&sid=AONE&xid=ddd5c3ff | |||
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