Abdominal Assessment Case Study SOAP Note
Abdominal Assessment 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-year-old 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)
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
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Analyze the subjective portion of the note. List additional information that should be included in the documentation.
Subjective Analysis
According to Ball et al, (2015) when treating a patient with generalized abdominal pain, it is important to collect a detailed subjective history of the pain in order to better narrow down possible differential diagnoses. Chief complaint needs to be “stomach hurts.” The HPI needs to include the timing and characteristics of abdominal pain, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. In the scenario, in the subjective part of the SOAP note, more information is needed about the history of the patient concerning the present condition (HPI) and the general health from the past, this could be achieved by asking more focused questions. More investigation into the diet of the patient and history before the condition should be inquired. Also, additional information about any changes in appetite and bowel movements is also needed. The history of present illness should incorporate data like onset, duration, characteristics, exacerbating, and alleviating symptoms as it relates to abdominal pain. Location is one of the most critical questions to ask before the beginning exam (Ball,2015). Specifying which part of the abdomen with clarifying questions asked during the ROS which is missing altogether. Patient reports of not using his medications would go under medications the last time he took them, needs to identify the reason for each medication, and why stopped. Negative finding for colon cancer listed could have been a differential diagnosis consideration, then needs to be listed under the Assessment section. Lastly, the family history is required to go back to three generations with 2 out of 3 documented. It seems as if this practitioner got sidetracked with his ROS and forgot to note the rest of the PMHx or forgot to finish it. The lifestyle and exercise questions for diabetes and hypertension are good practice and required for proper medical documentation (Ball, Dains, Flynn, Solomon, & Stewart, 2019). CAGE screening ruling out alcoholism. How much is “occasional” drinking? How many, how often, and any repercussions?
The objective portion of the note and additional information that should be included in the documentation.
Objective Analysis
In the objective part of the SOAP note, the documentation still needs more information on the general appearance of the patient. This includes the rate at which the patient answers questions, if all questions are answered appropriately, if the hygiene of the patient is good, the mood, and the posture. The result of the inspection and percussion of the abdomen was not given, although the auscultation was done and was noted to be hyperactive and pain to the left lower quadrant.
Physical examination is out of order. Systems uniformly listed in a certain order to match head to toe assessments. The general assessment is completely missing from this section. Only positive findings and pertinent negative findings needed for the objective part of the SOAP note. The body systems that are listed need to be in a particular order when used HEENT before Neck, Neck before Chest, and so on. The SOAP for the case study would be VS General, Skin, Chest, Abdomen, and Genitourinary (Ball et al., 2019). These areas contain all the organs that may be the cause of abdominal pain. There were two positive findings in which this practitioner needed to use palpation and a stethoscope. The negative results for the rest of the examination need documentation for palpation and auscultation. Lastly, if JR has a history of GI bleed, where is the CBC, skin pallor, cap refill? If JR is a diabetic with diarrhea, where is his blood glucose and CMP? What is the character of LLQ palpation findings? Mass/no mass. Rebound tenderness? Sharp/dull does it travel? The practitioner might have suspected with the mention of the father having no colon cancer. Needed are CBC, CMP, HbA1c, Abd x-ray, stool guaiac, and stool WBC. Also, the colorectal exam performed along with prostate screening. Referral for EGD/colonoscopy, especially with his high risk for colon cancer and history of GI bleed (Sullivan*, 2019).
Is the Assessment Supported by S/O Information?
The assessment is partly supported and partly not supported by the objective and subjective information. For example, the Gastroenteritis assessment is supported by the chief complaint of the patient where she states stomach pain, diarrhea, and nausea. According to Martin (2016), the symptoms of Gastroenteritis include stomach pain, watery diarrhea, fever, nausea, cramping and headache. The subjective data the patient reported supported the gastroenteritis assessment however, the objective part of the SOAP note is not considered in the assessment. The patient complained of generalized pain which is totally different from the left lower quadrant (LLQ) pain that was collected in the Objective data, but the left lower quadrant could also be a referred pain and need to be investigated further because serious medical conditions disguise with GI symptoms.
Diagnostic tests would be appropriate for this case, and how the results would be used to make a diagnosis
1. Stool occult test: This test will find out if there is blood in the stool or not. This is not a normal result. If there is presence of blood in the stool which cannot be clearly seen by the eye, then it would be an indication of a serious issue in the upper digestive tract.
2. Blood test such as Complete blood count (CBC), Comprehensive metabolic panel (CMP) Magnesium and Phosphorus and stool sample. Since the patient is having a low-grade fever, it is important to rule out an infection. The CMP would give a present health status of the kidneys, liver and electrolytes since the patient complains of frequent diarrhea.
3. Liver function test – as the name suggests, liver function tests are carried out to determine the functioning of the liver. The main role of the liver is to get rid toxic toxins from the body, and if this is not happening then the test could show if the liver is damaged. If toxins are not removed from the body, it could result to a lot of pain that could be felt in the abdomen.
4. Ultrasound of the abdomen – This is a painless procedure imaging that allows one to have a good view of all the organs in the abdomen which includes the kidneys, liver, gall bladder, spleen and pancreas.
5. X-ray of the Abdomen and CT abdomen and pelvic would be done lastly due to cost and after any positive result of the above test.
Would I accept or reject the diagnosis in the SOAP?
I would not accept the diagnosis due to the objective data of left lower quadrant pain. The subjective data point mostly to gastroenteritis, the patient has a low grate fever, diarrhea, nausea and vomiting and abdominal pain. The three possible conditions that may be considered as a differential diagnosis for this patient include:
1. Intestinal obstruction
This happens when food is blocked from passing through the large or the small intestines. According to the Mayo Foundation of Medical Education and Research (2015), the symptoms of intestinal obstruction include abdominal pains, stomach cramps, vomiting, constipation, and nausea.
1. Gallstones
This refers to solid materials that form I the gallbladder thereby leading to blockage. According to WebMD (2017), its symptoms include nausea, vomiting, indigestion, and stomach pain.
1. H. Pylori
This is infection of the stomach by bacteria. According to Colledge and Cafasso (2015), its symptoms include abdominal pain, vomiting, loss of appetite, bloating, and nausea.
1. Diverticulitis
This is the most common cause of the left lower quadrant pain, It is the inflammation of diverticula, that is caused by a tear, infection or swelling of the diverticula, which are small pouches which is caused by the weakness of the colon. The symptoms include left lower abdomen pain, fever, nausea, vomiting and abdominal tenderness. This is most likely my pick of diagnosis because it has both the subjective and objective data present. Although according to Almerie & Simpson (2015) diverticulosis of the bowel would have been diagnosed before a diagnosis of diverticulitis can be confirmed, this is best done with a CT abdomen.
1. Ulcerative colitis
Due to the patient history of GI bleed, this is a differential diagnosis. The symptoms include diarrhea, the color of stool is not received in the subjective data so there may be likely some trace of blood, abdominal pain, fatigue, fever, urgency to defecate. A stool sample test with a positive white blood cells would rule out ulcerative colitis and would also make us aware if there are other disorders.
References
Colledge, H., & Cafasso, J. (2015, September 13). H. pylori Infection: Causes, Symptoms, and Treatment. Retrieved from http://www.healthline.com/health/helicobacter-pylori?m=0#overview1
Martin, L. J. (2016, May 1). Gastroenteritis (Stomach ‘Flu’). Retrieved from https://www.webmd.com/digestive-disorders/gastroenteritis#1
Mayo Foundation for Medical Education and Research. (2015, December 31). Intestinal obstruction Symptoms and causes – Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/dxc-20168463
WebMD. (2017). Gallstones Picture, Types, Causes, Risks, Symptoms, Treatments. Retrieved from http://www.webmd.com/digestive-disorders/gallstones#2
Ball, J. 2 W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). 2Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
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