COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

            Client X is a 40 years old African American male.

Chief Complain

Difficulty while passing stooland pain in the belly.

History of Presenting Illness

The client complained of difficulty in breathing and pain in the belly when he visits the clinic. Additionally, he reports passing loose in the last seven days. Specifically, he claims to pass between 3 and 5 bowels daily with some mucus in the stool. He also reports of bloating and excess gas that was getting worseafter meals. However, he was partially relieved after a bowel movement. The abdominal pain and discomfort worsened throughout the seven days. Moreover, Client X complains of vomiting in the last two days. He vomited three times on the first day and six times on the second day. Additionally, he started experiencing a feveron the previous day. Furthermore, he reports having lost his appetite for the last two days.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

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Current Medications

The clinician questioned the client about any drug that he is currently taking. The client states that he is currently using an inhaler to manage asthma that he has been struggling with since childhood. Additionally, the client reveals that he is under the medication for mild depression. He started by taking citalopram20mg daily, which was later increased to 40 mg/day. This medication is usually combined with psychotherapy to enhance its effectivenessin managing the symptoms of mild depression.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Allergies

The client denies any food and drug allergies. However, he reports environmental allergies. Specifically, he reacts to dust mites, pollen, pet dander, and strong scents due to his asthmatic condition.

PMH

The client reports having been immunized for thetetanus boosters given in every ten years to all adults. Additionally, he states that he had undergone two major surgeries. The first surgery was heart valve repair, which was performed in February 2010 toreconnectvalve flaps. The client also reveals that laparotomy was conducted in August 2016 to repair a perforated bowel.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Soc Hx

The client is an English teacher in a local school based in the city. He likes swimming and playing rugby during his free time. Additionally, he spends time riding a bicycle with his five-year-old son during weekends and public holidays. He is married to one wife, Juliet, aged 35 years. They have two kids, a boy, and a girl. He uses alcohol, particularly during the weekends. He takes three bottles of beer on Saturday and five bottles on Sunday when he hangs out with his friends. However, the client denies the use of tobacco products. Upon being questioned about any working smoke detectors in the house, the client responded that he had one in his living room. These detectors indicate the level of smoke in the room, thus helping him manage his asthmatic condition. Additionally, the client states that his living environmentis free of stimuli that might accelerate his asthmatic condition. Finally, the client reveals that he has a strong support system. His family members and social groups have helped him cope with challenges associated with his health complications.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Fam Hx

The patient’s parents are deceased. His father died of colorectalcancer in 2012 while his mother died of heart failure in 2018. He had three siblings, two sisters, and one brother. His only brother was involved in a tragic road accident in November last year, which claimed his life. He attributes his mild depression to the loss of three close family members. His older sister struggles with Type 2 Diabetes, while the younger sister was diagnosed with post-traumatic stress disorder early this year. However, his wife and children are in good health condition.

ROS

General:Complaints of fever and loss of appetite. No change in sleep pattern, loss or gain of body weight, fatigue, or weakness.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Head: Headache or dizziness

EENT: No change in visual capacity, hearing problem, congested or runny nose, or sore throat.

Skin: No itchiness or rashes.

Cardiovascular: No pressure or pain in the chest. No heart palpitations.

Respiratory: No difficulty in breathing or sputum.

Gastrointestinal: No blood, anorexia, or nausea. Reports vomiting, diarrhea, abdominal pain, bloating, and excess gas.

Genitourinary: No burning while passing urine or change in urinating frequency.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Neurological: No dizziness, headache, or numbness in the extremities. Reports change in the bowel.

Musculoskeletal: No pain in muscles, joints, or back, or stiffness.

Hematologic: No bleeding or anemia.

Lymphatics: No change in the sizes of the nodes.

Psychiatric: No history of anxiety or PSTD. Reports mild depression.

Endocrinologic: No excessive cold or sweating.

Objective

Vital Tests

Weight: 148lbs; temperature: 92 degrees;height: 6ft; pulse rate of 89 bpm; and blood pressure: 141/93mm Hg.

Physical Exam

The client is stressed and has a fever. He is dehydrated due to vomiting and having bowel movements frequently.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Abdominal Test

The abdomen is stiff and slightly swollen with excessive gas. No palpable masses are detectable.

Rectal Test

No blood, abnormal masses, or enlarged liver are detected on checkup.

Assessment

Differential Diagnosis

The provided subjective data and physical assessment are not adequate to rule out the client’s condition. Therefore, differential diagnosis will be conducted to assess other possible conditions. The conditions that will be evaluated include carcinoid tumors, celiac disease, and colorectal cancer.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Carcinoid Tumor

The presented symptoms, objective data, and physical exam indicate that the client might be suffering from a carcinoid tumor. In most cases, this condition starts in the stomach, small intestine, appendix, rectum, or colon. No symptoms are noticed in the early stages of this condition. Some common clinical presentationsinclude abdominal pain, diarrhea, and vomiting(Rubin de Celis Ferrari et al., 2018). These symptoms are presented by the client, indicating the likelihood of a carcinoid tumor. Additionally, this condition is characterized by nausea, rectal pain and bleeding, redness, and inability to pass stool caused by intestinal blockage. However, symptoms were not presented by Client X. Therefore, the possibility of a carcinoid tumor is ruled out.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Celiac Disease

The provided data indicates that the client might have celiac disease. This condition is considered an immune reaction to gluten, found in barley, wheat, and rye. The immune response causes inflammation, which destroys the lining of the small. This condition prevents some vital nutrients from being absorbed in the body. It is mainly characterized by vomiting, diarrhea, abdominal bloating, and pain(Green et al., 2015).COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER. The client complains of vomiting in the last two days. He vomited three times on the first day and six times on the second day.Additionally, he reports abdominal pain and bloating. These symptoms indicate the possibility of celiac disease. Other significant celiac disease symptoms include constipation, foul-smellingstool, weight loss, anemia, and fatigue. Nonetheless, the client does not present any of these symptoms in the subjective data; neither was identified during a physical exam and diagnostic testing. The absence of these significant symptoms rules out the possibility of this condition.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Colorectal Cancer

The presented symptoms indicate the possibility of colorectal cancer. This condition is mainly characterized by a change in bowel habits(Nakayama et al., 2014). Some individuals with colorectal cancer experience diarrhea while others constipate. This issue persists for some days. The client complains of diarrhea in the last seven days indicating the possibility of this condition. Additionally, the client has a higher chance of colorectal cancer since his family has a history of this condition. His father died of colorectal cancer in 2012. Other significant symptoms of this disease include rectal bleeding and traces of blood in the stool. However, the client does not complain of these symptoms ruling out the possibility of colorectal cancer.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Plan

Proposed Treatment Interventions

A treatment plan for managing each of the conditions discussed above is required. First, IBS management will require the client to be referred for further assessment to a gastroenterologist who specializes in digestive health and complications related to the bowels, stomach, intestines, and bowels.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER. Therapeutic interventions, including medication, relaxation therapy, and psychoeducation, will also be required to manage this condition’s symptoms. Alosetron (Lotronex)0.5 mg twice a daywill be prescribed for this client. This dosage will later be increased to 1 mg orally twice a day if the client tolerates 0.5 mg twice a day. This drug will be preferred due to its efficacy and safety in managing the symptoms of IBS. According to Farmer et al. (2020), Alosetronrelaxes the colon and reduces waste flowin the lower bowel. The client will also be advised to relax to enhance the effectiveness of the administered medication. Finally, the healthcare provider will educate the patient on managing the presented symptoms by eating regularly and drinking excess fluids to avoid dehydration.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Additionally, various treatment interventions will be required to manage carcinoid tumors, celiac disease, and colorectal cancer.Carcinoid tumors will be handled through surgery and medication. The client will be given Xeloda Rx 950mg/m2 twice daily. According to Hendifar et al. (2017), this drug is effective in managingcarcinoid tumors in adults. The client will also be advised to avoid foods with high amounts of mines since they trigger serotonin’s secretion, which worsens the condition. Secondly, celiac disease will be managed through medication. Prednisone 9 mg/day will be administered to this client. According to Abbas et al. (2018), prednisone has a history of managing celiac disease symptoms. The client will also be educated on the significance of taking a strict gluten-free diet to boost the intestine’s healing. Finally, surgical removal of the tumor will be used to treat colorectal cancer. Adjuvant chemotherapy will also be performed to enhance the effectiveness of the surgical procedure.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Reflection

The treatment of this condition was educative. I learned about differential diagnoses that should be performed to a client with symptoms of IBS. I agree with the preceptor’s treatment since the proposed interventions have effectively managed symptoms and treated the discussed conditions. The case educated me that the combination of various therapies manages presented symptoms effectively. I would use similar treatment interventions to treat those conditions in the future. COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Episodic/FocusNote Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is herein the patient’s own words (e.g., “headache,” NOT “bad headache for 3 days”).

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATESfor the HPI might look like the following example:COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance).COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system).COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relativesshould be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General:Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Example of Complete ROS:

GENERAL:No weight loss, fever, chills, weakness, or fatigue.

HEENT:Eyes:No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN:No rash or itching.

CARDIOVASCULAR:No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:No shortness of breath, cough, or sputum.

GASTROINTESTINAL:No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

MUSCULOSKELETAL:No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC:No anemia, bleeding, or bruising.

LYMPHATICS:No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:No history of depression or anxiety.

ENDOCRINOLOGIC:No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e.,General: Head: EENT: etc.).

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

A.

Differential Diagnoses (list a minimum of threedifferential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

P.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently?COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.

Alsoinclude in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background).COMPREHENSIVE SOAP NOTE ON ANY GASTROINTESTINAL DISORDER.