SOAP wk 4
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MCPHS University *
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703
Subject
Medicine
Date
Feb 20, 2024
Type
docx
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4
Uploaded by MegaBadger2008
Chief Complaint: “I have had moderate to severe abdominal pain for past week” Subjective Data
HPI:
D.J. Is a pleasant, cooperative 68 year-old who presents to clinic with wife with complaints of fluctuating generalized abdominal pain accompanied by acute diarrhea 3-4x/day for past one week. He reports lack of appetite, only eating soft bland foods and a weight loss of approx. 10 lbs over past week. Reports fatigue and weakness. He denies any episodes of nausea or vomiting. Attempted to take OTC antacid without relief. Does report some relief with bowel movements. He reports the current abdominal pain as a 2/10 but states it has been much worse at home. Took his temperature at home and he reports he has not been febrile. Medications: Omega-3 fish oil PO daily, Pravastatin 20mg PO nightly. Reports taking OTC antacid (unsure of name) for his abdominal pain without relief. Allergies: Latex with reaction of rash and pruritis Hydrocortisone, reaction: rash.
Past Medical History: High cholesterol
Past Surgical History: Bilateral hip arthroplasty, 2015
Family History: Pt reports he had one sister, deceased from complications of Multiple Myeloma. Mother alive,
hx includes hypertension, hyperlipidemia, COPD. Father deceased, pt believes he also had hypertension and hyperlipidemia. Both paternal and maternal grandparents medical history unknown. Social History:
Marital status: Married 36 years
Number of children: Two
Highest level of education: Bachelor’s Degree
Occupation: Retired
Smoking History:
Smoking status: Daily smoker, 0.5 PPD x 50 years
Smokeless tobacco: Denies
Vaping use: Denies
Substances: Nicotine
Substance use and Sexual Activity:
Alcohol use: Denies
Illicit substance use: Marijuana, occasional use 2-3x/month
Sexually active: Yes
Sexual partner: Female
Immunizations
Pt reports he is up to date on all vaccines and immunizations and does not request any today. Established Chronic Conditions (With ICD-10 codes). Hypercholesterolemia ICD-10.E78.00
Differential Diagnosis
1.
Diverticulitis ICD-10.K57.92
While typically abdominal pain from diverticulitis is located in the left lower quadrant, the pain may also be generalized. This can be accompanied by tenderness, fever, and leukocytosis (Goolsby & Grubbs, 2023). Other symptoms include loose stools, nausea, vomiting, and a positive occult blood test. 2.
Parasitic Infection ICD-10.B89
Certain infections such as giardia lamblia, which is transmitted by fecally contaminated water or food can cause symptoms the patient is describing such as diarrhea, bloating, flatulence, cramps, anorexia, and weight loss (Goolsby & Grubbs, 2023). The symptoms may occur as late as 2 weeks after exposure and may last longer than a month. Full Review of Systems
GENERAL/CONSTITUTIONAL
:
Denies fever, night sweats. Reports fatigue and weakness. Reports weight loss of approximately 10 lbs in past week d/t loss of appetite.
OPHTHALMOLOGIC
:
Denies blurred vision, changes in vision, double vision, or sensitivity to light.
ENT
:
Denies hearing loss, infections of the oral mucosa, change in voice, difficulty swallowing, ringing in the ears, toothache.
RESPIRATORY
:
Denies cough, shortness of breath. No wheezing.
CARDIOVASCULAR
:
Denies palpitations, tachycardia, chest pain. Denies irregular heartbeat. Denies cold hands or feet. No edema. GASTROINTESTINAL
:
Reports diarrhea 3-4x/day for one week, denies nausea and vomiting or constipation. Reports abdominal pain and cramping before having a bowel movement. Pain does not radiate.
HEMATOLOGY
:
Denies easy bruising, blood clots, prolonged bleeding. GENITOURINARY
:
Denies frequent urination, painful urination, loss of bladder or bowel control. Reports positive flatus. Denies indigestion. Denies pus blood or mucus in stool. MUSCULOSKELETAL
:
Denies back pain, abnormal movements of extremities, muscle aches, neck pain. Denies weakness to extremities.
SKIN
:
No nail changes or new rashes. No erythema jaundice or bruises. NEUROLOGIC
:
Denies imbalances, difficulties with coordination, no difficulty speaking, gait within normal limits, no dizziness, or syncopal episodes. Denies headaches. Denies memory loss. Denies seizures. Denies tremors. PSYCHIATRIC
:
Denies depression and anxiety. Denies hx of suicide attempts, thoughts of self-harm, or homicidal ideation. Objective Data
Vitals: BP 140/97 P 102 RR 18 O2 98% RA T 96.7
Height, Weight, BMI: Ht 5’6 Wt 223lbs BMI 36
Lab/Diagnostic Study Results: No lab work completed prior to appointment. Labs ordered. Physical Exam Findings
General: Alert and oriented x3, pleasant and cooperative with interview and assessment. Good hygiene, well-
nourished, appropriate range of affect. Looks stated age. Insight and judgement are good. Does not appear in any apparent distress but reports 2/10 abdominal pain.
Skin: Skin is warm, dry, and intact. Normal coloration and good skin turgor indicating good hydration. Without
jaundice ecchymosis or erythema.
HEENT:
Head
: Atraumatic and normocephalic
Eyes
: PEERLA, EOMI, conjunctiva clear
Ears
: Clear, tympanic membranes pink and intact
Neck: The neck is supple, no lymphadenopathy, no carotid bruits, no masses. No JVD. Thyroid is not enlarged.
Mouth
: Oral mucosa pink and moist, good dentition
Chest
: Symmetrical, trachea midline. Lung sounds clear to auscultation. Cardiac: Regular rate and rhythm, no murmur or gallop
Abdominal
: Soft and symmetric without organomegaly, mass or tenderness. Bowel sounds active in all four quadrants. No inguinal hernia. No guarding. Back
: No scoliosis, lordosis, or kyphosis
Hematological
: no petechiae, ecchymosis, hematoma, splenomegaly, or enlarged lymph nodes
Neurological
: Cranial nerves appear intact. Deep tendon reflexes brisk and symmetrical. Speech is clear. Musculoskeletal
: Full range of motion in all joints. No muscle spasms. No deformities. varicosities. Both upper and lower extremity pulses are palpable and symmetrical. Extremities are warm to touch, suggesting good circulation.
Respiratory: The lungs are clear on auscultation, bilaterally. There are no crackles, rales, wheezes, or other abnormal sounds. Her breathing pattern is even, and chest expansion is symmetrical.
GI: Bowel sounds are normoactive. The abdomen is soft, non-distended, and there are no palpable masses. No hepatomegaly or splenomegaly is noted upon palpation.
GU: No Costovertebral angle (CVA) tenderness is noted upon palpation or percussion, indicating
no renal issues.
Musculoskeletal: On inspection and palpation, there are no joint deformities or swelling. She displays a good range of motion in all major joints. Neuro: Ms. Johnson is alert and oriented to person, place, and time (x3). Her cranial nerves are intact. No deficits in sensation are detected during the examination.
Assessment
Health exam with abnormal findings (Z00.121)
Plan
1.
Diagnostic Studies
a.
CBC auto with differential. WBC count may be elevated in diverticulitis. The hematocrit and hemoglobin count may be decreased in colon cancer or acute bleeding so that should also be ruled out (Goolsby & Grubbs, 2023). b.
Comprehensive metabolic panel. This measures the patient’s fluid and electrolyte status, a common complication of diarrhea. It will also show how the liver and kidneys are functioning. 2.
Stool culture
a. Fecal occult blood test. In diverticulitis the fecal occult blood test may show positive for blood, which
may be seen to the naked eye.
b. Fecal leukocytes. Leukocytes will be elevated in situations of inflammatory diarrhea, with bacterial diagnoses such as C. difficile or salmonella. c. Giardia antigen. ELISA stool tests may be used to determine if the person is infected with Giardia, however not as specific as an O&P screen. d. Ova/parasite screen. Microscopic evaluation of the stool remains the standard of testing which successfully identifies giardia (Goolsby & Grubbs, 2023). e. CDIFF tox DNA. Invasive bacteria such as C. difficile could be an organism that may cause diarrhea. 3. Follow-up/Referral
a. If the diagnosis continues to be uncertain and the results show negative, the patient may need an abdominal CT with contrast or an ultrasound to determine the cause of abdominal pain. b. If results come back positive on fecal occult blood test, the pt may need additional screening such as a
colonoscopy to rule out colorectal cancer (Goolsby & Grubbs, 2023). c. If parasitic agents show to be the cause of his symptoms, antiparasitic agents may be prescribed (Cash
et al., 2021). Health Promotion
Pt was educated on health risks associated with smoking and was encouraged to quit. Attends yearly physicals with PCP and has adequate access to healthcare. Pt was educated on the importance of handwashing techniques to prevent the spread of infection and boiling water if he suspects contamination. He was also encouraged to maintain proper hydration as the most complicating factor with diarrhea is dehydration. Interprofessional Collaboration
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Care discussed with DO and agrees with plan. Referrals for lab work sent as well as directions given to pt regarding how to obtain a stool sample. Citation
Cash, J. C., Glass, C. A., & Mullen, J. (2021).
Family practice guidelines
. Springer Publishing Company.
Goolsby, M. J., & Grubbs, L. (2023). Advanced assessment: Interpreting findings and formulating differential diagnoses
. F.A Davis Company. Reflection on Care
Information obtained subjectively and objectively with patient