SOAP Note: Acute Problem-Based Assessment Essay

Patient identifying data: Initials: EP,  Age: 78, Gender: Female

Source and reliability (if warranted):

Primary Language: English, Interpreter ID: N/A

Date of Visit: 10/20/2020

Visit Method: Face-to-Face  or Telehealth: Telehealth

Site of visit: Out-patient Primary Care (internal medicine or family practice), Urgent care, Skilled Nursing Facility, Other (specify) Shadow Health Clinic. SOAP Note: Acute Problem-Based Assessment Essay.

SUBJECTIVE:

Chief complaint: Abdominal pain and lack of bowel movements. Patient reports “I have pain in my belly and I’m having some difficulty with going to the bathroom”.

History of present illness:

Esther Park states that she has been feeling discomfort for the last five days. Ms. Park reports pain with a steady onset that worsened in the past two to three days. When asked about the pain location, she identifies it as being in the lower abdomen and not being localized.

Ms. Park rates the pain as 6 out of 10 and defines the character as dull and cramping. She emphasizes that the pain is intermittent with aggravating factors such as eating and physical activity.  When asked about treatment and relieving factors, the client reports that resting helps and taking small water sips is ineffective in bring relief. She has not taken pain medication for the stomach.

Initially, she rated her pain as a 2 out of 10 but it has now increased in intensity to a 6 out of 10. However; she describes the pain as fluctuating in severity and as primarily a generalized discomfort in the abdomen. Ms. Park reports recent difficulty in engaging in usual activities and states that she has low energy levels. She reports constipation in most of the past five days and has not tried to treat constipation. Ms. Park experienced diarrhea about six months ago, which had an unexpected onset lasting one day. She has no blood or mucus in stool and notes a minimal decrease in the regularity of urination. Recently she has had darker urine, but denies presence of blood. In the past few days Ms. Park she has had decreased thirst and fluid intake. SOAP Note: Acute Problem-Based Assessment Essay. She perceives her symptoms as not severe enough to warrant a trip to the hospital; noting that her daughter insisted she visit the clinic. In a review of systems, she denies recent fever, chills, sweats, bladder problems, or sore throats. She feels ‘bloated’ and has lost her appetite.

ORDER A PLAGIARISM -FREE PAPER NOW

PMHHypertension, 1996

PSH Cesarean-section, 1982

Cholecystectomy, 1984

; she had a C-section at the age of 40 and

cholecystectomy at age 42.

Accidents/Injuries: Denies

The client reports no accidents or injuries during her shadow health visit.

Hospitalizations: Following the Cesarean-section, 1982

Following the Cholecystectomy, 1984

FH

Ms. Park’s mother, deceased at age of 88, had a history of hypertension and Type II diabetes mellitus. Her father, deceased at age 82, had a history of hypercholesterolemia and hypertension. Maternal grandparents (deceased) had a history of diabetes mellitus Type II and coronary heart disease. Paternal grandparents (deceased) had a history of CVA, obesity and hypertension. Ms. Park has two brothers who are alive, the oldest is 81; he has a history of hypertension. The youngest is 80, with a history of prostate cancer, hypertension, and hypercholesterolemia. Ms. Park has two children, age 48 and 46 years old; both are healthy. SOAP Note: Acute Problem-Based Assessment Essay.

Ms. Park is living with her daughter and describes her familial support system as strong. she had toast for breakfast; her most recent meal. She normally eats three meals a day and denies regularly eating snacks. Her typical breakfast is toast, soup for lunch and chicken or fish and rice for dinner. She does not take any fiber supplements or other activities to include fiber in her diet. She consumes vegetables every? one to three days and fruits after every three to four days. Oral hydration?

When asked about her physical activity level, Ms. Park reports an increased level of mobility and independence. She notes that her activity level is moderate. She does not use any illicit drugs or smoke. She reports low alcohol consumption of at least one night a week; white wine is her typical drink.

Allergies:

latex allergy reaction? No known medication or food allergies

Current Medications:

Accupril for hypertension , 10mg, taken orally, taken daily at 8 am (last taken?).  Denies use of over the counter medications.

Health Maintenance/Immunizations:

Ms. Park states that her immunizations are up to date, she get her influenza vaccine this season? , annual health check-ups and her most recent pap smear was ten years ago. Her colonoscopy was also ten years ago.

Overall, the client feels that her level of health and activity is suitable for her age.

Sexual preference and practices:

LMP: the client reports that her commencement of menopause was at age 54. Ms. Park reports she is heterosexual and is currently sexually active (how many partners? Do they use any methods of STI prevention?)

Ms. Park was asked about her constitutional health, to which she denies any fresh weight changes, chills, fever or night sweats. However, she reports short-term feelings of fatigue and exhaustion. SOAP Note: Acute Problem-Based Assessment Essay.  She says she has been experiencing bloating and increased gas and loss of appetite, but denies nausea and vomiting.  She has no history of bladder problems, painful urination, urinary incontinence, or UTIs and no respiratory issues.

OBJECTIVE:

Vitals: blood pressure 110/70, O² sat 99%, pulse 92, respirations 16, temperature 37.0 C.

General: Ms. Park was an edgy and flushed, appearing older woman. She appeared a bit distressed and was smirking at times.

HEENT: Cardiovascular: S1, S2, no murmurs, gallops, or rubs. No S3 and S4.

Skin: Moist, mucous membranes, normal skin turgor, no tenting. No lower extremity edema.

Respiratory: breathing was quiet and unlabored. She could construct full sentences and lung sounds were clear to auscultation where? Throughout?

Abdominal: 6 cm scar in RUQ and 10 cm scar at the midline in the suprapubic region. no skin discoloration and bowel sounds were normoactive in all four quadrants; no bruits; no friction sounds over spleen or liver; tympany presides with scattered dullness over LLQ; abdomen soft in all quadrants. Any tenderness with palpation? An oblong mass is noted in the LLQ with mild guarding, distension; no organomegaly; no CVA tenderness; liver span 7 cm at MCL and no hernias.

Rectal: no hemorrhoids, fissures or ulceration; strong sphincter tone, fecal mass in the rectal vault.

Pelvic: no inflammation or irritation of the vulva, abnormal discharge, bleeding, masses or growth or tenderness upon palpation.

Urinalysis

ASSESSMENT:  

The patient’s bowel sounds were normoactive in all quadrants, with no friction sounds or bruits. During percussion, scattered dullness was spotted in the LLQ, which is indicative of feces in the colon. The client’s abdomen was soft to palpation and mild guarding together with the oblong mass; indicating feces were founded in the LLQ. The patient had no CVA tenderness; liver span 7 cm at MCL and no splenic dullness. A digital rectal exam showed a fecal mass in the rectal vault. No aberrations were noted during the pelvic assessment, eliminating the likelihood of pelvic inflammatory disease. SOAP Note: Acute Problem-Based Assessment Essay. Ms. Park’s urinalysis was normal, ruling out the possibility of urinary tract infection. There were no signs of cardiovascular abnormalities or dehydration. The client’s health and symptoms indicate that she has constipation. Ms. Park’s differential diagnoses, in order of priority are internal obstruction, diverticulitis, and constipation.

Internal obstruction ICD-10CM diagnosis K56.69: The mechanical impairment or total arrest of the movement of the contents of the intestines resulting from a pathology that blocks the bowels (Puja Hari, 2016). Common symptoms are cramping pain and inability to pass stool. SOAP Note: Acute Problem-Based Assessment Essay.

Diverticulitis ICD-10CM diagnosis K57.92: according to Kamal, Baiomi, & Balar (2019). Diverticulitis is an infection or inflammation of one or more pouches of the digestive tract. The disease is more prevalent in persons over the age of 40. Symptoms encompass abdominal pain, fever, change in bowel habits and fever.

Constipation ICD-10CM diagnosis K59.0: occurs when a person’s bowel movements are uncommon, causing difficulty in passing stool. Typical causes are diet changes, physical inactivity and insufficient fiber intake (Forootan et al., 2018). Being a woman, older age, and taking certain medications are significant risk factors for constipation. Symptoms include bloating, abdominal cramps, and the inability to pass stool.

Health Promotion/ Disease Prevention: primary, secondary, and/or tertiary

for Ms. Park comprises the following;

• 4 – Increase fiber intake, including vegetables and fruits (Forootan et al., 2018).
• Increased intake of whole-grain cereals.
• 4 – Increased fluid intake (Munch et al., 2016).
• Avoidance of caffeine and alcohol; they deplete water sources in the body.

PLAN

• Diagnostic tests are warranted to rule out differentials; abdominal X-rays should be conducted to diagnose internal obstruction.
• If a clinician concludes bowel obstruction is a high probability, which is a medical life threatening emergency. The client will be instructed to remain NPO and sent to the ER from the office for further work up (testing and diagnostics such as? Please use an evidence -based guideline) to rule out obstruction. SOAP Note: Acute Problem-Based Assessment Essay.
• Health promotion and disease prevention interventions include patient education on increasing her fluid intake, moderate physical activity and increasing fiber intake.
• Testing and diagnostics planned should include an examination of the patient’s red and white blood cells.
• Non- medical interventions: increasing fluid, physical activity and fiber intake.
• Follow-up care is vital to determine how the patient responds to non- pharmacological interventions.
• For follow-up care, Ms. Park should return to the clinic after a week to evaluate the effectiveness of the interventions. 

References

Forootan, M., Bagheri, N., & Darvishi, M. (2018). Chronic constipation. Medicine, 97(20), e10631. https://doi.org/10.1097/md.0000000000010631

Kamal, M. U., Baiomi, A., & Balar, B. (2019). Acute Diverticulitis: A Rare Cause of Abdominal Pain. Gastroenterology Research, 12(4), 203.

Munch, L., Tvistholm, N., Trosborg, I., & Konradsen, H. (2016). Living with constipation—older people’s experiences and strategies with constipation before and during hospitalization. International Journal of Qualitative Studies on Health and Well-Being, 11(1), 30732. https://doi.org/10.3402/qhw.v11.30732

Pujahari, A. K. (2016). Decision making in bowel obstruction: A review. Journal of Clinical and Diagnostic Research. https://doi.org/10.7860/jcdr/2016/22170.8923

SOAP Note Grading Rubric – modified for NUR580Fa20

Per the template…

PMH: List each known health condition and include date of initial dx, if known

PSH: List each w/date of surgery

Please follow the template….

Review of Systems: Pertinent to problem goes above in the HPI, all others go here as appropriate. See AHA textbook for details. SOAP Note: Acute Problem-Based Assessment Essay.

Smirking: Definition

adjective

1. smiling in an irritatingly smug, conceited, or silly way.

Did you mean to document smirking? Perhaps was the patient grimacing from her abdominal pain?

PLAN:

Write a holistic plan of care for the one selected highest priority differential above. Include a minimum of two evidence-based guideline used to guide your POC.

Author/Student Name:

Date completing assignment:

Patient identifying data: Initials: _____________, Age: _______. Gender: __________

Source and reliability (if warranted): ________________________________________

Primary Language: ___________________ Interpreter ID: ______________________

Date of Visit: _______________

Visit Method: Face-to-Face __________________ or Telehealth _______________

Site of visit: Out-patient Primary Care (internal medicine or family practice) _________, Urgent care _____, Skilled Nursing Facility_______, Other (specify) _______________.

SUBJECTIVE:

Chief complaint: Fever and a productive cough with difficulty in breathing on attempting physical activity for the past one week. The cough has been there for the last four months and has progressively worsened.

History of present illness: The patient is a 65 year-old Caucasian male presenting with a complaint of fever, dyspnea on exertion, and a progressively worsening productive cough that brings forth whitish-yellow phlegm. He reports a previous history of these symptoms, having experienced them before at a lesser degree. He first noticed the current symptoms about five months ago when the cough started. SOAP Note: Acute Problem-Based Assessment Essay. It has been progressively worsening ever since. However, one week ago he started having fever and difficulty in breathing on attempting physical activity. The cough is located deep inside the chest and is intermittent in duration. It is a deep crackling cough with copious sputum. The cough is aggravated by activity, smoking and smoke and relieved by rest and taking homeopathic chamomile tea. The timing of the cough is mostly at night but it is still present to a lesser extent during the day. The patient rates its severity at 7/10. He denies chest pains, wheezing, or tightness of the chest.

PMH:

1. Hypertension, diagnosed in the year 2000.
2. Obesity with a current BMI of 33.2 kg/m² (diagnosed in 2012).

PSH:

1. Cholecystectomy in 1998
2. Appendectomy in 2005

Accidents/Injuries:

1. Bathroom fall in 2019 with lateral subluxation of the patella.

Hospitalizations:

1. 1990 for pneumonia
2. 1998 for surgery
3. 2005 for surgery

FH: Both of his parents are deceased. The father died of a heart attack (MI) while the mother died of complications of diabetes mellitus. His father was also hypertensive. He has two siblings. The brother is hypertensive and the sister has type II diabetes and hypertension on medication. He is a father of two children, both of which are in good health so far. SOAP Note: Acute Problem-Based Assessment Essay.

Social History (detailed): The patient admits to smoking at least one pack of cigarettes per day since 1980 or the last 40 years. He has led a sedentary lifestyle most of his life since he was a manager at a local car assembly plant. His hobbies include watching movies and reading books. He admits to taking etoh over the weekends with friends in moderate quantities. He is living in a suburban neighborhood with adequate amenities, clean air, and security. He is still married with two adult children and lives with his wife. He has college education and is now retired on pension. He is an avowed atheist and loves meat and all meat products. He admits to detesting vegetables but occasionally takes “a fruit here and there”. He denies ever abusing any substance.

Allergies: NKDA, no food allergies or allergies to environmental irritants such as dust, pollen, or smoke.

Current Medications:

1. Metoprolol 50 mg orally BID (prescription, last taken on the morning of the visit to the clinic).
2. Chamomile tea 1 cup PO (300 cc) TDS (homeopathic remedy, last taken the morning of visit).
3. Mucinex 600 mg orally BID (OTC, last taken on the morning of the visit)

Health Maintenance/Immunizations: He reports having all his required immunizations as a child. His last Tdp booster injection was in 2015, his pneumococcal vaccine was in 2019, and his latest influenza vaccination was in January 2020.

Sexual preference and practices: He is heterosexual, married and with two children.

LMP: N/A

Review of Systems:

General: He denies having any weakness or fatigue but reports fever. Denies recent weight loss.

HEENT: He denies diplopia, tearing, or blurred vision. Denies otorrhea, earache, or tinnitus. Also denies sneezing, rhinorrhea, or epistaxis. He does not have a sore throat or dysphagia. SOAP Note: Acute Problem-Based Assessment Essay.

Integumentary: He denies any rashes or itching.

Gastrointestinal: Denies nausea, vomiting, or diarrhea. He reports no change in his bowel habits and had his last bowel movement the previous night.

Cardiovascular: He denies palpitations, chest pain, or cold extremities.

Genitourinary: Denies frequency of micturition, dysuria, or any discharge.

Neurological: Denies having any fainting attacks, gait problems or paraesthesia. He also denies bladder and bowel incontinence.

Musculoskeletal: Denies arthralgia, myalgia, and joint stiffness. He does not have back pain.

Endocrinologic: He denies polydipsia and polyphagia. He also denies excessive diaphoresis, heat intolerance, or hormonal therapy.

Lymphatics: He denies lymphadenopathy or a history of splenectomy.

Hematologic: Denies a history of clotting or blood disorders.

Psychiatric: Denies ever having depression, anxiety, r any other mental condition.

Allergic/ Immunologic: Denies hives, asthma, eczema, or immunosuppression. He last got tested for HIV in 2010 and the test was negative.

OBJECTIVE:

General: A&O x 3. He is dressed appropriately for the weather and time of the day. He has no apparent gait disturbance or any notable tics and mannerisms. Vital signs: T 98.9°F; BP 135/75 mmHg; RR 19/ min; PR 82 b/m; SpO₂ 94%; Wt 110 kg; Ht 1.82 m; BMI 33.2 kg/m². SOAP Note: Acute Problem-Based Assessment Essay.

HEENT: Head atraumatic and normocephalic. PERRLA. EOMI. No otorrhea and no cerumen in external auditory canal. Non-tender pinna and tragus. Tympanic membranes intact with no fluid levels visible bilaterally. Nasal turbinates not swollen. No evidence of polyps or rhinorrhea. Teeth have no cavities and oropharynx is moist. The throat is not erythematous and there is no exudate present.

Respiratory: Coarse crackles present. Reduced breath sounds over lung fields. The expiration phase is prolonged. Faint forced expiratory wheezes apparent at lung bases bilaterally. Breathing not labored.

ORDER A PLAGIARISM -FREE PAPER NOW

Cardiovascular: S1 & S2 audible with no murmurs or bruit. No pedal edema.

Diagnostic Tests

1. Laboratory: WBC 12,900 x 10⁹/L (leucocytosis); CRP 6 mg/L.
2. Radiology: CXR shows hyperinflated lungs and a flat diaphragm
3. Spirometry (pulmonary function test or PFT): FEV₁/FVC ratio = 0.6
4. SpO₂: 94%

ASSESSMENT: 

1. Chronic obstructive pulmonary disease or COPD (J44.9): This is the most likely diagnosis for this patient as his symptoms agree with the GOLD standard diagnostic criteria for COPD that is a productive cough, dyspnea, history of smoking, and FER (FEV₁/FVC) of <0.7 (GOLD, 2017; American Thoracic Society, 2015).
2. Asthma (J45): This is the second most likely differential diagnosis since there is comorbid obesity. But there should be a history of asthma which is lacking (Hammer & McPhee, 2018; GOLD, 2017).
3. Congestive heart failure or CHF (I50.9): The symptoms would also be true for CHF, only that the CXR does not indicate an enlarged heart of pulmonary edema (Hammer & McPhee, 2018).

Health Promotion/ Disease Prevention: primary, secondary and/or tertiary

• 9: Meeting with patient for health education on the need to stop smoking and to reduce weight. An ongoing smoking cessation educational intervention will be commenced, and dietary changes will be advised for weight reduction.

PLAN:

• Start tiotropium (Spiriva) 18 mcg (2 inhalations) orally OD (Katzung, 2018).
• Repeat spirometry in one month.
• Stop smoking going forward (taper off).
• Eat more fresh fruits and vegetables and reduce intake of fats and oils.
• Avoid processed foods and sugary beverages.
• Next follow up visit in one four weeks. SOAP Note: Acute Problem-Based Assessment Essay.

References

American Thoracic Society (2015). ICD-10-CM Coding for pulmonary medicine American Thoracic Society clinical practice committee webinar. https://www.thoracic.org/professionals/clinical-resources/resources-for-practices/ats-coding-billing-issues/resources/icd10-pulmonary-webinar.pdf

Global Initiative for Chronic Obstructive Lung Disease [GOLD] (2017). Pocket guide to COPD diagnosis, management, and prevention: A guide for health care professionals. https://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14^th ed. McGraw-Hill Education. SOAP Note: Acute Problem-Based Assessment Essay.