Exam (elaborations) NR 509 Abdominal Pain SOAP NOTE

Exam (elaborations) NR 509 Abdominal Pain SOAP NOTE t Weight BP HR RR Temp SPO2 Pain Allergies 157.48 (5’2”) 54 kg (120 lbs) 110/ 70 92 16 37.0 C 99% 6/10 Medication: Latex (Rxn - itchy skin rash) Food: NKA Environment: NKA History of Present Illness (HPI) Chief Complaint (CC) “Belly 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 Onset She is unsure what caused it, but she started having a difficult time going to the bathroom Location Whole belly but mostly the lower part Duration Consistent for the past 5 days. Pain worse 2-3 days ago Characteristics Dull and crampy Aggravating Factors Movement and eating Relieving Factors Rest Treatment Rest Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Accupril 10 mg Daily 24 years Hypertension 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. Click or tap here to enter text. S: Subjective Information the patient or patient representative told you NR 509 Abdominal Pain SOAP NOTE 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. 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. 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. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. 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. Hypertension – diagnosed at age 54 Gallstones - age 42 C-section – two in her early 40s Cholecystectomy Colonoscopy – two; most recent was 10 years ago – nothing to report Immunizations – up to date Bowel movement – usually every day Has not travelled in several years Nutrition - typically eat three meals but sometimes skips breakfast and skips lunch if not feeling hungry Breakfast: piece of toast Lunch: soup Dinner: rice with fish or chicken Fiber source – at least one vegetable every 1-2 days and a fruit every 3-4 days Fluid intake – two glasses a day; last few days, it has been difficult to drink much; chamomile tea Avoids caffeinated drinks 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. Widowed - husband passed 6 years Lives at home with daughter Retired RN Volunteers at a church charity drives Alcohol – one glass of white wine every Sunday Does not smoke or use illicit drugs Exercise – classes at the community center (water aerobics and pilates); walking 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. Mother - hx of hypertension and DM type II; deceased at 88 - cause unknown Father - hx of hypertension and hypercholesterolemia; decreased at age 82 - cause unknown Maternal grandmother - hx of diabetes Maternal grandfather - hx of coronary artery disease; deceased from MI Paternal grandparents - hx of obesity, CVA, and hypertension; grandmother passed away from cancer; grandfather lived to be very old, into his 90s - unsure of cause of death Siblings: brother (80) - hx of hypertension, hypercholesterolemia, prostate cancer brother (81) - hx of hypertension Son (48) - healthy Daughter (46) - healthy 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. Constitutional Skin HEENT Fatigue – low energy Weakness - low energy Fever/Chills - denies Weight Gain - denies Weight Loss - denies Trouble Sleeping - denies Night Sweats - denies Other: Click or tap here to enter text. Itching - denies Rashes - denies Nail Changes - denies Skin Color Changes - denies Other: Click or tap here to enter text. Diplopia - denies Eye Pain - denies Eye redness - denies Vision changes - denies Photophobia - denies Eye discharge - denies Earache - denies Tinnitus - denies Epistaxis - denies Vertigo - denies Hearing Changes - denies Hoarseness - denies Oral Ulcers - denies Sore Throat - denies Congestion - denies Rhinorrhea - denies Other: Click or tap here to enter text. Respiratory Neuro Cardiovascular Cough - denies Hemoptysis - denies Dyspnea - denies Wheezing - denies Pain on Inspiration - denies Sputum Production Choose an item. Syncope or Lightheadedness - denies Headache - denies Numbness - denies Tingling - denies Sensation Changes Choose an item. Chest pain - denies SOB - denies Exercise Intolerance - denies Orthopnea - denies Edema - denies Murmurs - denies Palpitations - denies Faintness - denies OC Changes - denies Claudications - denies PND - denies Other: Click or tap here to enter text. Choose an item. Choose an item. Other: Click or tap here to enter text. Speech Deficits - denies Other: Click or tap here to enter text. MSK GI GU PSYCH Pain - denies Stiffness - denies Crepitus - denies Swelling - denies Limited ROM Choose an item. Redness - denies Misalignment - denies Other: Click or tap here to enter text. Nausea/Vomiting - denies Dysphasia - denies Diarrhea – one episode 2-3 days ago Appetite Change – decreased appetite past couple of days due to abdominal pain Heartburn - denies Blood in Stool – denies Abdominal Pain - cramply, dull; the whole abdomen but mostly the lower; past 5 days but has gotten worse the past 2-3 days; pain aggravated by movement and eating; relieved by rest Excessive Flatus - denies Food Intolerance - denies Rectal Bleeding - denies Other: Urgency - denies Dysuria - denies Burning - denies Hematuria - denies Polyuria - denies Nocturia - denies Incontinence - denies Other: urinating slightly less than usual Stress – regarding to the stomach pain Anxiety – regarding to the stomach pain Depression - denies Suicidal/Homicidal Ideation - denies Memory Deficits - denies Mood Changes - denies Trouble Concentrating - denies Other: Click or tap here to enter text. Click or tap here to enter text. GYN Rash - denies Discharge - denies Itching - denies Irregular Menses – N/A Dysmenorrhea – N/A Foul Odor - denies Amenorrhea – N/A LMP: N/A Contraception - denies Other: menopause at age 54 Body System Positive Findings Negative Findings General Choose an item. Click or tap here to enter text. Alert & oriented Dressed appropriately Skin Choose an item. Click or tap here to enter text. No tenting HEENT Choose an item. Click or tap here to enter text. Skull and facial features symmetrical Nasal mucosa moist and pink Oral mucosa moist and pink O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Respiratory Choose an item. Click or tap here to enter text. Breath sounds in all areas No adventitious sounds heard Neuro Choose an item. Click or tap here to enter text. Click or tap here to enter text. Cardiovascular Choose an item. Click or tap here to enter text. No edema in bilateral lower extremities S1 and S2 audible No extra heart sounds Musculoskeletal Choose an item. Click or tap here to enter text. Click or tap here to enter text. Gastrointestinal Choose an item. Scarring on lower abdomen Tenderness reported on light palpation - left lower quadrant Guarding and distention reported on light palpation Abdomen symmetrical and flat No bruit in abdominal aorta Normoactive bowel sounds in all quadrants Deep palpation - palpable mass in left lower quadrant Fecal mass in rectal vault in digital rectal exam No bruit in bilateral renal arteries No bruit in bilateral femoral arteries No bruit in bilateral iliac arteries No friction rub upon auscultation for liver and spleen Upon percussion, some areas dull and some tympanic Spleen tympanic upon percussion Liver span between 6-12 cm Pt did not react to CVA tenderness Aortic width 3 cm or less Liver palpable Spleen, bladder, and bilateral kidneys not palpable Genitourinary Choose an item. On urinalysis, dark yellow and acidic Urine clear and no additional substances detected Psychiatric Choose an item. Click or tap here to enter text. Stressed and anxious about the abdominal pain Gynecological Choose an item. Click or tap here to enter text. No abnormal findings on pelvic exam Problem List 1. Abdominal pain 6 Click or tap here to enter text. 11 Click or tap here to enter text. 2 Constipation 7 Click or tap here to enter text. 12 Click or tap here to enter text. 3 Decreased appetite 8 Click or tap here to enter text. 13 Click or tap here to enter text. 4 Low fluid intake 9 Click or tap here to enter text. 14 Click or tap here to enter text. 5 LLQ palpable mass 10 Click or tap here to enter text. 15 Click or tap here to enter text. Diagnosis ICD-10 Code Pertinent Findings Constipation K59.00 Fecal mass in rectal vault in digital rectal exam Intestinal obstruction K56.60 Crampy abdominal pain; loss of appetite; constipation; vomiting Acute diverticulitis K57.92 Pain that has been constant and persisted for several days; vomiting; abdominal tenderness; constipation or, less commonly, diarrhea Diagnostics: List tests you will order this visit Test Rationale/Citation CBC An elevated WBC indicates an infection (Rezapour, Ali, & Stollman, 2018). BMP Patient stated her fluid intake has been less the past few days. An increased ratio to BUN to creatinine A: Assessment Medical Diagnoses. Provide 3 differential diagnoses 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. may indicate dehydration (Bak, Tsiami, Greene, 2017). Also, I want to do a CT abdomen with contrast so I need to know what her kidney function is. Albumin Pt sometimes skips breakfast and/or lunch and eats rice with fish or chicken for dinner. Want to check her nutritional status because malnutrition has been associated with increased healthcare-associated costs including longer hospital length of stay and increased rates of major and minor complications (Bharadwaj et al., 2016). CT abdomen A palpable mass in the left lower quadrant was noted on physical examination; therefore, a CT scan with contrast is appropriate (Mendelson, 2015). CT scan can also show if there is an abdominal obstruction. Click or tap here to enter text. Click or tap here to enter text. Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Miralax 1 capful PO daily PRN 1 week May take 1-3 days to produce a bowel movement. If there is poor response then a stool softener plus stimulant laxative may need to be added (Mounsey, Raleigh, and Wilson, 2015). 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. 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. 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. 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. Referral/Consults: Nutritionist Rationale/Citation A nutrition assessment will diagnose