NURS 612 Gastrointestinal Tina Jones SOAP( LATEST QUESTIONS & ANSWERS)

Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan) C hief C o m plaint What brought you here today (eg. headache) “I’ve been having stomach pain for a while.” Histo r y of P r ese nt Illn ess Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset Patient is a 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She reports the pain started about a month ago. She states that she experiences pain daily starting after meals usually lasting “a few hours.” She reports pain is a 5/10 in her upper stomach after eating. She reports pain is a 7/10 when lying down. She describes the pain similar to heartburn. She notes it to increase with consumption of food. She states pain is worse after fast food and spicy food. She reports decreased appetite and not wanting to eat because of anticipation of pain. She denies any recent changes to her diet besides an increase in water intake. She denies coffee intake but does drink diet cola daily. She states that the pain usually goes away several hours after eating but that she does treat the pain “every few days” with an over the counter antacid with some relief. She reports burping after meals and denies any recent weight loss. She denies any gastrointestinal history but does report her grandfather passed away from colon cancer. Location Duration Character Aggravating/associate d factors Relieving factors Temporal factors – other things going on Severity P ast M e dic al Histo r y Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, Adult illness: diabetes, asthma Childhood illness: asthma at 2.5 years old Immunizati