Case Study SOAP Note

ABDOMINAL ASSESSMENT Case Study SOAP Note

 

Subjective:

• CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
• HPI: JR, 47 y/o WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
• PMH: HTN, Diabetes, hx of GI bleed 4 years ago
• Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units QHS
• Allergies: NKDA
• FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
• Social: Denies tobacco use; occasional ETOH married, 3 children (1 girl, 2 boys)

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Objective:

• VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Skin: Intact without lesions, no urticaria
• Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
• Diagnostics: None

Assessment:

• Left lower quadrant pain
• Gastroenteritis

 

Additional Information that Should Be Included in the Documentation of Subjective Data

According to Ball et al. (2015), it is critical to obtain a detailed abstract history of the torment when treating a patient with generalized stomach or abdominal pain in order to narrow the range of possible differential diagnoses. The main complaint should be “stomach or abdominal pain.”More information about the patient’s historical background regarding the current condition (HPI) and overall wellbeing from a previous time is required in the subjection section of the SOAP note in this case, which could be accomplished by asking more engaged or focused questions. More information about the patient’s overall health, eating habits and history prior to this condition is required, which could be obtained by asking more engaged or focus questions. It is also necessary to provide additional information about any changes in appetite and defecation or bowel movement. The historical context of the current illness should include information such as the beginning or onset, duration, qualities or characteristics, intensifying or exacerbating, and mitigating or alleviating symptoms in the case of the abdominal pain. It is critical to retain information on the nature of the pain, such as whether it is transitory or confined, whether the severity is increasing or decreasing, and where it originates and ends. One of the most basic questions to ask before beginning the test is about the location of the pain (Ball,2015).The patient should also be asked what he was doing before the pain started. Identifying which parts of the abdomen that the pain is felt most as well as responding to questions posed during the ROS is missing. This information is critical in narrowing down to the absolute most likely diagnose. Case Study SOAP Note

Despite the patient’s mention of diarrhea, mote information about bowel and urinary habits should be included. This includes the length and frequency of diarrhea episodes in a day, relieving and aggravating factors, and other diarrhea related symptoms. Incontinence, hesitancy, dysuria, urgency, and increased frequency of urination should all be documented. Still on the subject of urinary habits, details about the odor, color, and discomfort felt after or during a bowel movement should be provided. It is critical to rule out any potential abdominal pain side effects such as nausea and vomiting. Clearly, the patient had a 4year history of GI bleeding. As a result, details such as the absence or presence of blood in the vomitus or stool, as well as color and smell should be included.

Patient reports of missing to take medications would be filed under meds the last time he took them, necessitating a distinction between the justification for each medicine and why it should be discontinued.Also, a differential conclusion thought to be a negative finding for colon malignant growth or cancer should be recorded in the Assessment section. Finally, the family history must return to three generations, of which two out of three is documented. This healthcare provider ROS appears to have been derailed, and he failed to take note of or complete the remainder of the PMHx.Inquiries about lifestyle and exercise for diabetes and hypertension are acceptable practice and require legitimate clinical documentation (Ball, Dains, Flynn, Solomon, and Stewart, 2019). CAGE testing can assist you in avoiding alcohol addiction. What exactly is meant by “intermittent or occasional” drinking? How many, how frequently, and what are the ramifications? Case Study SOAP Note

 

 

 

Additional Information that Should Be Included in the Documentation of Objective Data

In the objective a section of the SOAP note, the documentation actually requires more data on the patient’s outward appearance. This includes how quickly the patient responds to questions, whether all inquiries are addressed appropriately, whether the patient’s cleanliness or physical appearance is acceptable, and the patient’s disposition and stance.Despite the fact that an auscultation was performed, which revealed hyperactivity and pain in one lower quadrant on one foot, the outcome of the midsection inspection and percussion of the abdomen was not disclosed.The actual assessment is incorrect. To coordinate with head-to-toe evaluation or assessment, frameworks or systems are consistently documented in a specific request. This section is devoid of any sort of overall evaluation. Only certain discoveries and relevant negative discoveries are required for the objectivedata or section of the SOAP note. when using HEENT, the body systems are listed in a particular order, HEENT before Neck, Neck before chest etc. The SOAP for the contextual investigation would be VS General, Skin, Chest, Abdomen, and Genitourinary (Ball et al., 2019). These areas contain all of the organs that could be causing stomach pain. In two of the positive stomach or abdominal pain, this provider is expected to use palpation and a stethoscope. Negative results for palpation and auscultation must be documented for the remainder of the assessment.Finally, if JR has a history of GI drain, where are his CBC, skin pallor, and capillaryrefill data? Where are JR’s blood glucose and CMP levels if he is a diabetic with the runs? Since the patient is on hypertension and diabetes medication, it is necessary to include data for blood sugar level. What is the LLQ palpation discoveries’ persona? Either there will be a mass or there will not be a mass or rebound tenderness. Is it sharp or dull as it travels? The following Lab test are needed; CBC, CMP, HbA1C, Abdominal x-ray, Stool guaiac, and stool WBC. Given his high risk of colon cancer and history of GI bleed, a referral for EGD/colonoscopy is a good option (Sullivan, 2019).

 

Is the Assessment Supported by the Subjected or Objective Information

The assessment is partially supported and partially not supported by subjective and objective data. For example, the patient’s abdominal grumbling, which includes stomach pain, loose bowels, and sickness, supports the diagnosis of gastroenteritis.According to Martin, gastroenteritis symptoms include stomach pain, watery loose stools, fever, sickness, squeezing, and migraine or headache (2016). Despite the fact that the patient-specific information supported the gastroenteritis diagnosis, the objectivepart of the SOAP note is not taken into account in the assessment.The patient complained generalized pain, which differed significantly from the pain noted in the Objective data in the left lower quadrant (LLQ). However, the pain in the left lower quadrant may be an alluded or referred pain that needs to be investigated further because real illnesses can be concealed by GI side effects. Case Study SOAP Note

 

 

Diagnostic Tests

The most appropriate characteristic tests that would be used to determine or come up with a diagnose of the patient current presentation are a total blood count (CBC) and a liver function test (LFTs). Completing a tumor markers test is also important. A CBC would show a normochromic pallor, as well as sickliness or anemia and thrombocytosis, all of which are signs of pancreatic disease.Increased levels of bilirubin, basic phosphatase, serum amylase, and lipase on the LFTs indicate obstructive jaundice (Fazzalari et al., 2019). The sugar or carbohydrateantigen 19-9, which would be raised to levels of 100U/ml due to pancreatic malignant development from the common level of 33-37U/ML iscurrently the most incredible tumor marker test(Fazzalari et al., 2019).In this case, it is strongly advised to use Computed Tomography scan (CT scan) rather than Magnetic Resonance Imaging (MRI). A stomach CT scan can show the entire pelvis and mid-region. The presence of lower-thickness wounds on CT will aid in the confirmation of pancreatic malignant damage or growth.Examining the skin, stomach, or abdomen now revealed no obvious disclosures, such as the rigid concept of rigidity to propose a mass. Furthermore, there is no clinical, social, or familial history of pancreatitis or pancreatic malignancy.Regardless, the patient had abdominal and stomach pain, looseness of the bowels, and it was later revealed that, patient could eat despite some irrelevant squeamishness. Furthermore, due to the patient’s gastroenteritis condition, the pain was limited to the lower quadrant of the abdomen.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accept or reject soap

I will refuse to accept the review due to the goal details of left lower quadrant torture. In the majority of cases, the abstract information points to gastroenteritis; the patient has a low mesh fever, loose bowels, sickness and heaving, and stomach pain. Three conditions that could be considered a differential finding for this patient are as follows:

 

Irritable bowel syndrome

When food is unable to pass through the large or small digestive tracts, this occurs. According to the Mayo Foundation for Medical Education and Research, symptoms of intestinal obstruction include stomach pains, cramps, heaving, clogging, and sickness (2015).

 

A gallstone is a type of gallstone.

Strong materials that structure the gallbladder in such a way that it becomes clogged are referred to as this. WebMD lists some of the symptoms as queasiness, retching, acid reflux, and stomach pain (2017).

 

The bacteria H. Pylori causes stomach ulcers.

This is a stomach disease caused by microbes. Symptoms include stomach pain, regurgitation, loss of appetite, bulging, and sickness, according to Colledge and Cafasso (2015).

 

Diverticulitis is a digestive disease.

The most well-known cause of left lower quadrant torment is diverticula aggravation, which is caused by a tear, contamination, or growth of the diverticula, which are small pockets caused by a shortcoming of the colon. Left lower midsection pain, fever, sickness, regurgitation, and stomach discomfort are among the symptoms.

 

 

 

 

Irritable bowel syndrome (UCS) is a form of colitis

This is a differential conclusion due to the patient’s history of GI drain. The signs and symptoms include loose bowels, stomach pain, weakness, fever, and the need to poop. The color of the stool isn’t recorded in the abstract information, so there may be a hint of blood, stomach torment, weakness, fever, and the need to poop.A positive feces white platelet test would rule out ulcerative colitis and alert us to any other problems. Case Study SOAP Note