Assignment: Practicum Experience – Episodic SOAP Note #2. After completing this week’s Practicum Experience, reflect on a patient who presented with abdominal pain. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care.
example and grading rubic attached.
Comprehensive SOAP
Patient Initials: P.S. Age: 72-year-old Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “Terrible pain and bloating in my stomach, and reflux.”
History of Present Illness (HPI):
P.S. is a 72-year-old Caucasian male presenting to the office twice over the last 2xweeks due to onset of acute abdominal stabbing pain with bloating, and esophageal reflux. He states that he attended an event and ate “way too much food”. Patient reports greater than 10-pound weight loss over the past few months, and complaints of increased fatigue on exertion. He states that he went to the ER last week, was given a GI cocktail and Protonix which improved symptoms, but symptoms returned a couple of days later, sending him to the office. On the ER visit, labs, EKG, and cardiac workup completed and negative. Gallbladder U/S obtained and shows gallstones, thickening of gallbladder walls and enlargement. WBC 12.6, elevated liver enzymes. He was given Librax and Cipro. He rated his pain at 9/10.
Medications:
- Lisinopril 10mg, 1 tablet po daily
- Omeprazole 20 mg, 1 tablet po daily
- Crestor 10 mg, 1 tablet po at bedtime
- Cipro 500 mg, 1 tablet twice daily x 10 days. Rxed in ER. Dx: Gallbladder enlargement/elevated WBC
- Librax 5/2.5mg, 1 tablet po three times daily x 10 days. Rxed in ER. Dx: Pain and spasm.
Allergies:
NKDA
Past Medical History (PMH):
1.) Hyperlipidemia
2.) Hypertension
3.) Gastroesophageal reflux (GERD)
Past Surgical History (PSH):
- Detached retina surgical repair 2009
- Right inguinal hernia repair
Sexual/Reproductive History:
Heterosexual
2 children
Personal/Social History:
Denies smoking, alcohol or illegal drug use.
Immunization History:
Immunizations are up to date. He received the influenza vaccine 3xweeks ago. Pt denies receiving Pneumococcal vaccine.
Significant Family History:
Father deceased, DX Lung Cancer. Mother deceased, DX Uterine Cance. Daughter and Son positive for hypertension.
Lifestyle:
Married, 2 adult children. Retired high school teacher. Currently works at Panhandle Technical College in maintenance department. Lives in Bonifay, Florida, owns his home.
Review of Systems:
General: 10-pound weight loss, + fatigue since the illness started; no fever, chills or night sweats
HEENT: Denies vision changes, wears glasses for reading, his last eye exam was 1 ½ years ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. He has had no recent ear infections, tinnitus, or discharge from the ears. Denies epistaxis, nasal polyps or recent sinus infection. Denies ulceration, oral lesions, gingivitis, gum bleeding, difficulty chewing or swallowing.
Neck: Denies pain, injury, or stiffness.
Respiratory: Denies SOB, cough, wheezing or hemoptysis. No hoarseness. Chest x-ray clear. Denies + PPD’s.
CV: Denies chest pain, palpitations, history of murmur; no edema, or claudication. No history of MI or CHF. No pacemaker.
GI: Abdominal pain with worsening after eating. Denies nausea, vomiting, diarrhea or constipation. Positive for reflux. Denies blood in stool or dark colored stools. Positive abdominal rebound tenderness (Murphy’s sign). Gallbladder with gallstones and thickened walls and enlargement on U/S.
GU: Denies dysuria, frequency, hematuria, or incontinence. No history of STDs.
MS: Denies joint pain or swelling, no arthritis or gout. Full range of motion. No history of trauma or fractures.
Psych: Denies anxiety, depression, suicidal or homicidal ideations. Recent sleep disturbance due to abdominal pain.
Neuro: Denies syncopal episodes, dizziness, numbness, tingling, or headache. Denies changes in hearing, taste, vision or smell. No speech deficits. Denies gait disturbance or problems with coordination/balance. No falls or seizure history.
Integument/Heme/Lymph: Denies rashes, pruritis, or bruising. No history of cancer. No bleeding or clotting disorders. No gland enlargement or tenderness.
Endocrine: Denies night sweats, hot and cold intolerances or hair changes.
Allergic/Immunologic: Denies any immune deficiencies or allergies.
OBJECTIVE DATA
Physical Exam:
Vital signs:
Wt: 172 lbs; Ht: 5’7; BMI 26
B/P 144/76, Temp: 98.4 oral, Pulse: 68 and regular, Resp: 18, non-labored, SPO2 98% on RA.
General: 72-year-old, well developed, alert & oriented white male resting with wife in room. Appears to be comfortable.
HEENT: PERRLA, EOM intact. Mucus membranes pink and moist. Trachea midline. Thyroid without enlargement. Bilateral tympanic membranes intact.
Neck: Carotid no bruit or jugular vein distention. Full ROM. No cervical lymphadenopathy.
Chest: Symmetrical thorax
Lungs: Clear bilateral, anteriorly and posteriorly, respirations even and unlabored. No wheezing or rhonchi.
Cardiovascular: Regular rate, no murmurs, rubs or gallops. S1S2 audible. PMI left 5th intercostal space. No cyanosis, cap refill < 3 sec.
Abdomen: soft, tenderness. No masses. Positive Murphy’s sign. Pain in RUQ on palpation, Bowel sounds active x 4 quads.
Musculoskeletal: Full ROM all extremities, no muscle atrophy or joint tenderness.
Neuro: CN II – XII grossly intact, DTR’s intact.
Skin/Lymph Nodes: Warm & Dry, Skin intact. No edema noted, no rash, or bruising noted.
ASSESSMENT:
Labs:
CBC – WBC 12.6, elevated liver enzymes.
Diagnostics:
Radiology: Abdominal Ultrasound, Gallstones, Gallbladder wall thickness and enlargement to 10.6 cm
CXR – no abnormalities
ECG – normal sinus rhythm
Differential Diagnosis:
Gastroenteritis – an inflammatory condition of the stomach and intestines most commonly caused by a virus spread by close contact of persons, contaminated food or water, and infected surfaces. Common symptoms include abdominal pain, bloating, malaise, muscle aches, nausea. (Torpy, 2012). This diagnosis was ruled out due to the patient did not have watery stools, generalized abdominal pain or nausea and vomiting as the primary chief complaints.
Peptic Ulcer Disease – refers to a painful sore or ulcer in the lining of the stomach (gastric ulcer) or duodenum (duodenal ulcer). The pain is described as an upper abdominal discomfort with burning and ache, bloating, nausea, poor appetite and weight loss (Roy, 2016). This diagnosis was ruled out because these pains can be relieved by eating foods, and the pain was not throbbing or gnawing type pin.
Gastritis – inflammation in the lining of the stomach which can be caused by bacteria or anti-inflammatory medications. Gastritis can be acute or chronic, and associated with abdominal pain and bowel problems (Findley, et al., 2015). This condition was mainly ruled out due to the U/S results. This patient does have the signs and symptoms of this condition but elevated due to the U/S.
Primary Diagnosis:
Acute Cholecystitis – confirmed by radiology. Gallbladder disease is a common cause of upper abdominal pain, and acute cholecystitis is one of the most common reasons for hospital admission in patients with acute abdominal pain Imaging plays an important role in the management of cholecystitis because gallbladder disease usually has a good prognosis provided diagnosis and management occur expeditiously. Acute cholecystitis is due to gallstone impaction in the gallbladder neck or cystic duct in 90–95% of cases, with bile stasis, gallbladder ischemia, cystic duct obstruction, and systemic infection responsible for most cases of acalculous cholecystitis (Gore, 2014). Visualization of gallbladder wall thickening in the presence of gallstones using ultrasound has a positive predictive value of 95% for the diagnosis of acute cholecystitis (Ralls, 2018).
PLAN:
Acute Cholecystitis may be fatal without emergency cholecystectomy. A referral was made to Dr Mitchum for 10/7/2019 at 0700. The patient is aware that he cannot eat anything 12 hours prior to surgery time and must arrive 30 minutes early to complete additional paperwork. Dr Mitchum is a well-known general surgeon in Bonifay. H&P, ultrasound, Labs and xrays faxed to Dr Mitchums office.
The patients Librax is discontinued and is given a single IM injection of 60mg Ketoralac for pain relief. As an alternative therapy the pt is advised to eat small frequent meals to minimis discomfort and elevate the HOB when resting for help with reflux discomfort.
For diagnostic testing the patient has completed all within the ER visit, no additional testing needed unless surgeon requests. Scheduled Cholecystectomy, Monday morning per Dr. Mitchum.
Surgical site care and pain management per surgeon orders. Liquid diet after surgery, advance as tolerated to bland diet. Continue home medications after surgery. For health promotion the pt is educated on low fat diet. No lifting or pulling x 2 weeks. For disease prevention strategies the patient is educated on the possible return of symptoms post cholecystectomy and on the signs/symptoms of colitis syndrome. Follow up in 2 weeks at office or before if needed.
Reflection:
This was a busy, but educational week in practicum. I was asked by my preceptor to complete a history and physical on this patient from a follow-up post an ER visit for abdominal pain. While completing the assignment for my preceptor, it prepared me for this week’s SOAP note. The patient was alert, oriented and knowledgeable about his condition which helped greatly in collecting an accurate history. The initial H&P that I presented to my preceptor was less than optimal and needed much improvement, as noted with copious amounts of my omissions written in red ink all over my paper. With her instructions, suggestions and guidance, I wrote the H&P over and it looked much better. Although it wasn’t perfect, and a few signs of red ink were still present, I have now completed this assignment for the third time for her review. I am so grateful for the learning experience I have been afforded.
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Student Signature Date
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Preceptor Signature Date
Reference
Findley, J., Kirsner, J., Palmer, W., & Pullman, T. (2015). Chronic Gastritis. The American Journal of Medicine. Retrieved from http://www.amjmed.com
Roy, S. (2016). Clinical Study of Peptic Ulcer Disease. Retrieved from http://www.alliedacademies.org
Torpy, J., Lynm, C., & Golub, R. (2016). Viral Gastroenteritis. JAMA Network. Retrieved from http://www.jamanetwork.com
Gore RM, Yaghmai V, Newmark GM, Berlin JW, Miller FH. (2014). Imaging benign and malignant disease of the gallbladder. Radiol Clin North Am 2014; 40:1307-1323
Ralls PW, Colletti PM, Lapin SA, et al. (2018). Real-time sonography in suspected acute cholecystitis: prospective evaluation of primary and secondary signs. Radiology 2018; 155:767-771
