Nursing

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

• Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate. Provide a review of systems.
• Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
• Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.
• Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

PLEASE USE FOCUSED TEMPLATE NOT NARRATIVE

ANSWER

Focused SOAP Note Template

Patient Information:

S

CC (chief complaint): The patient is complaining of a stomach pain

HPI (history of present illness): Max is an 80-year old male who came into the clinic complaining of stomach pain, associated with nausea and vomiting. Max has a history of hypertension (HTN) and gastroesophageal reflux disease (GERD). Max has a pacemaker that was placed 10 years ago for third degree heart block.

• Location: Head
• Onset: 4 days
• Character: Cramping abdominal pains that affects organs in the abdomen.
• Associated symptoms: vomiting and nausea
• Timing: Occurs occasionally but worsens after eating
• Relieving factors: Rolaids makes it bearable but not totally better
• Severity: 7/10 pain scale

Current Medications: The patient used Rolaids to ease the stomach pain. The patient used Rolaid since it is a combination anti acid that is used to treat stomach upset, indigestion and heartburn. The patient chewed 2 tables twice every day. Ideally, a patient can take medications such as Rolaids and Pepto Bismol to ease a stomach ache before visiting a physician.

Allergies: No significant allergies

PMHx: Max has a history of hypertension, gastroesophageal reflux disease and third degree heart block.

Social and Substance Hx: No significant social and substance history

Fam Hx: No significant family history

Surgical Hx: Max has a pacemaker implanted 10 years ago for third degree heart block.

Mental Hx: No significant mental history

Violence Hx: No significant current or historical violence incidents

Reproductive Hx: No significant reproductive history.

ROS (review of symptoms)

GENERAL: Max complains of cramping abdominal pain, vomiting and nausea. No fevers, no weight loss, fatigue, appetite, temperature or weakness.

HEENT:

Head: Denies any headache

Eyes: Denies blurred vision, visual loss, eye pain or double vision.

Ears, Nose, Throat: Denies hearing loss, ear pain, nasal obstruction, nosebleeds, tinnitus, harness or sore throat.

SKIN: Denies any itching, bruising, lacerations, open wounds or skin rashes.

CARDIOVASCULAR: No palpitations, no chest pains, check discomfort or arrhythmia history.

RESPIRATORY: No cough, denies SOB, and no sputum production shortness of breath.

GASTROINTESTINAL: Complains of abdominal pains, vomiting, nausea or diarrhea.

GENITOURINARY: No burning on urination.

NEUROLOGICAL: No headache, numbness, dizziness, paralysis, ataxia, syncope.

MUSCULOSKELETAL: Denies back and join pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No history of splenectomy. No enlarged nodes.

PSYCHIATRIC: Denies anxiety and depression

ENDOCRINOLOGIC: Denies reports of cold or sweating. No polydipsia or.

ALLERGIES: Denies history of hives, asthma or rhinitis.

O (objective)

Physical exam:

Vital signs: The patient’s vital signs are normal. Bp: 90/60 mm Hg, 16 breaths per minute and pulse of 72 beats per minute. The patient record normal hair texture, scalp tenderness, normal sight, normal hearing, no lesions, external ears normal, presence of smell, no lymphadenopathy, no thyromegaly, bruits, and neck supple

Diagnostic results:

To accurately develop the differential diagnoses, the abdominal x-ray and an abdominal CT scan will be done. The abdominal x-ray may assist in finding the cause of abdominal pain and vomiting. The x-ray results can detect a blockage, kidney stones, and perforation within the intestines. Therefore, a close examination of the abdomen is required. An abdominal CT scan will be done to examine the blood vessels, organs and bone in the abdomen (Tamburrini et al., 2019)

Results: The test results of the abdominal x-ray were indeterminate; The CT scan indicates that Max has a small bowel obstruction.

A (assessment)

Differential diagnoses:

Gallstones (Cholelithiasis)- This involves the existence of gallstones which are concretions formed in biliary tract of the gallbladder. Gallstones cause severe and sudden abdominal pains (Gecse and Vermeire, 2018). The pain is much felt in the center of the abdomen and tends to spread to the shoulder blade. The pain is constant and can sometimes be triggered by eating food and may occur at any time of the day or even wake one during the night.

Diverticulitis- This is the inflammation or infection of pouches that may form on the intestines. The most collective symptom for the inflammation is a sharp cramp like pain that is usually on the lower side of the abdomen (Reddy and Cappell, 2017). Other symptoms include nausea, chills, fever, vomiting, diarrhea and constipation. The pain may persist and remain constant for some days. The symptoms tend to last for several days but may exceed if not treated.

Inflammatory bowel disease- This is an intestinal disorder that leads to prolonged digestive tract inflammation. A viral or bacterial infection of the digestive tract can lead to swelling and irritation of the digestive tract (Gecse and Vermeire, 2018). Ulcerative colitis and Crohn’s disease cause sores and swelling in the lining of the digestive tract as well as symptoms such as vomiting, diarrhea and abdominal pain.

 P (plan)

An effective treatment plan involves comprehensive assessment of the observed and expressed needs of the patient. The treatment plan will begin with understanding the history of the patient and examining the onset consequences and causes of the abdominal pains. The physical examination and general screening will determine the possible causes of abdominal pains. The main tests are CT scans and Xrays of the abdomen to examine the patient’s illness. For cramping pain medication will be required to relieve vomiting and nausea. To treat the small bowel obstruction, a bowel decompression by nasogastric tube will be done (Jackson and Cruz, 2018). In case the intestines are blocked completely, a surgery will be required to identify the cause of the bowel obstruction which may require the diseased segment removed or resection. The patient will be educated about the health complication in order to participate in the intervention process. The health provider will offer the best ways to manage the bowel obstruction and discuss with the patient to choose the treatment that patient is likely to recover without long lasting effects.

Reflection

The SOAP note is an effective way for physicians to document patient’s information in an organized and structured way. The SOAP note guides physicians in clinical reasoning to diagnose, assess and treat the patient based on the information they offered (Gossman, Lew, Ghassemzadeh, 2020). It is important for clinicians to emphasize on the clarity and quality of patient’s notes to acquire accurate details. The review of symptoms uncovers symptoms that are not mention by the patient in the chief complaint. In clinical decision making process, differential diagnosis and treatment are essential in arriving to an accurate diagnosis. Considering patient factors such as ethnic group, age, social history and family history is essential health promotion and prevention since these factors affect timely diagnosis.

References

Gecse, K. B., & Vermeire, S. (2018). Differential diagnosis of inflammatory bowel disease: imitations and complications. The Lancet Gastroenterology & Hepatology, 3(9), 644-653.

Gossman, W., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. In StatPearls [Internet]. StatPearls Publishing.

Jackson, P., & Cruz, M. V. (2018). Intestinal obstruction: evaluation and management. American family physician, 98(6), 362-367.

Reddy, S. R. R., & Cappell, M. S. (2017). A systematic review of the clinical presentation, diagnosis, and treatment of small bowel obstruction. Current gastroenterology reports, 19(6), 28.

Tamburrini, S., Lugarà, M., Iaselli, F., Saturnino, P. P., Liguori, C., Carbone, R., … & Marano, I. (2019). Diagnostic accuracy of ultrasound in the diagnosis of small bowel obstruction. Diagnostics, 9(3), 88.