Soap Note (Abdominal Pain and GI Problem)

“I abruptly began having upper right abdominal pains five hours ago that is not subsiding”

G.B is a 38-year-old African-American female that comes to the hospital with a chief complaint of upper right abdominal pain that began 5 hours before seeking medical intervention in this facility. The pain started suddenly, it is sharp, persistent, worsens with movement, and on a scale of 1-10 the patient rates the pain as an 8. She denies utilizing any form of relief and treatment for the pain. Patient mentions she is experiencing nausea but denies having vomiting or diarrhea episodes.

v  Atorvastatin 10mg PO daily for hyperlipidemia

v  Synthroid 75 mcg PO daily for hypothyroidism

v  Portia 0.15mg PO daily for oral contraceptive

Allergies:  She has no known food and drug allergy

Medication Intolerances: No known medical intolerances

Chronic Illnesses/Major traumas: G.B has hypothyroidism and hyperlipidemia. However, she denies having trauma.

Hospitalizations/Surgeries: She has had one surgery for the delivery of one of her children

G.B has a positive family history for pancreatic cancer (her father, 70-year-old) and hyperlipidemia and hypertension (Her mother, 65-year-old)

She is a graduate that works in a local bank. She is married and stays with her husband and two children. She confesses consuming fast foods during lunch times due to the tight schedule at the workplace. Moreover, she drinks wine every evening before sleeping. However, she denies smoking cigarettes, and exercising.

She denies having changes in weight, fatigue, fever, chills, night sweats, or energy level

Patient denies having cardiovascular symptoms such as chest pain, palpitations and edema.

G.B denies having rashes, bruising, bleeding or skin discolorations as well as any changes in lesions or moles.

Patient denies cough, wheezing, hemoptysis, dyspnea, or history of pneumonia or TB

She denies using corrective lenses, blurring and visual changes of any kind.

G.B mentions that she has a sharp right upper quadrant abdominal pain and a nauseated feeling. However, she denies vomiting or diarrhea, history of constipation, hepatitis, hemorrhoids, presence of black tarry stools or watery stools or eating disorders. Her last bowel movement was in the previous night.

She denies having ear pain, hearing loss, ringing in ears and discharge

She is devoid of urinary urgency, frequency, burning, and changes in color of urine. Patient reports she is on Portia oral contraceptives.  Last pap smear exam was 2 years ago and it had normal findings.  She denies having a history of STDs and has one sexual partner, her husband.

G.B denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness and throat pain

She has no episodes of back pain, joint swelling, stiffness or pain, and fracture history

She reports that doing SBE monthly and has no lumps, bumps, or changes to the breast.

She is devoid of syncope, seizures, transient paralysis, weakness, paresthesias or black out spells

She fails to mention having bruises, blood transfusion history, night sweats, swollen glands, increased thirst, increased hunger, cold or heat intolerance. G.B has a negative HIV status

She has no psychiatric history.

G.B is an adult African-American female who has facial grimace and is guarding the abdomen because of pain. She is alert and well oriented to time, place and person, as well as she is cooperative during the interview.

She has normal skin color, warm, clean, and intact with no rashes or lesions.

Her head is of normal shape with no abnormal findings, lesions noted.

Eyes: PERRLA. EOMs are intact. She has no conjunctival or scleral injection.

Ears: Canals are patent. Both TMs are pearly gray with positive light reflex and landmarks easily seen.

Nose: Nasal mucosa is pink in color, has normal turbinates and devoid of septal deviation.

Neck: Supple. Full ROM. Has no cervical lymphadenopathy as well as occipital nodes. She is of thyromegaly or nodules. The oral mucosa is pink and moist. Her pharynx is non-erythematous and without exudate. The teeth are in good shape and repair.

S1 and S2 are present with regular rate and rhythm. Extra sounds, clicks, rubs or murmurs are absent. Capillary refill is within  in 2 seconds, which is normal. Pulses 3+ are throughout.  She presents devoid of edema.

She has a symmetric chest wall.  Respirations are regular and easy. Lungs are clear to auscultation bilaterally.

Her abdominal girth indicates abdominal obesity. Bowel sounds are active in all 4 quadrants. Abdomen is rigid and tender upon palpation. G.B has a Positive Murphy’s sign. She has no masses and hepatosplenomegaly.

She has no breast lumps and tenderness. Her breasts are devoid of discharge, palpable lesions, dimpling, wrinkling or discoloration of the skin.

A non-distended bladder with no CVA tenderness noted. Genitals remain unexamined.

She has a full ROM seen in all 4 extremities as evident by the patient being able to move about the exam room.

Speech is clear and of good tone. Posture is erect, her balance is stable and gait is normal.

Alert and well oriented. She is dressed appropriately with clean clothes. She maintains eye contact throughout the interview. Her speech is soft, clear and of normal rate and cadence. Her answers to questions are appropriate.

Urinalysis- within normal limits

CBC- WBC 9.6

Amylase- 144

Lipase- normal

ALP- 158 IU/L

Bilirubin- Normal

AST- 45 U/L

1. Acute Cholecystitis (K81.0): Both the G.B’s subjective and objective data point out to the classic features in a person with acute cholecystitis. That is for sure because G.B possesses predisposing factors for acute cholecystitis (female gender, oral contraceptives utilization, medications for hyperlipidemia and eating of food with high fat content). Moreover, a positive Murphy’s sign as well as presence of gallstones and wall thickening of the gallbladder as visualized in the ultrasound is also suggestive of the cholecystitis (Copstead-Kirkhorn & Banasik, 2014).
2. Acute pancreatitis (K85.9): Of the essence to this condition are various signs and symptoms that are worth noting. The manifestations include abdominal pain, vomiting, anorexia, nausea, diarrhea and low-grade fever. Central to its development are various predisposing factors, namely, drinking alcohol, infections and medications like ARVs. As for the physical assessment findings, Cullen’s or Grey-Turner’s sign are present in these conditions (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2013). Given the absence of these physical assessment findings in G.B, her diagnosis cannot be acute pancreatitis.
3. Peptic Ulcer Disease (K27.9): Primarily, PUD risk factors include tobacco smoking, long-term use of drugs such as NSAIDS and some antibiotics, burns, Helicobacter pylori infection, pancreatitis, hepatic disease, Zollinger-Ellison syndrome and Crohn’s disease. Postprandial gnawing epigastric pain radiating to the upper right shoulder that subsides with food consumption is a common feature for persons with PUD (Buttaro, et al., 2013). In consideration of these ideal features of PUD, it is beyond doubt that G.B’s presentation is not reflective of this condition.

 Final Diagnosis

Acute Cholecystitis (K81.0): Both the G.B’s subjective and objective data point out to the classic features in a person with acute cholecystitis. That is for sure because G.B possesses predisposing factors for acute cholecystitis (female gender, oral contraceptives utilization, medications for hyperlipidemia and eating of food with high fat content). Moreover, a positive Murphy’s sign as well as presence of gallstones and wall thickening of the gallbladder as visualized in the ultrasound is also suggestive of the cholecystitis (Copstead-Kirkhorn & Banasik, 2014).

Further testing: None

Medication:

Tylenol 650mg PO TDS or PRN for the abdominal pain

Zofran 4mg PO QID or PRN for the nausea

Synthroid 75 mcg PO daily for the hypothyroidism (Buttaro, et al., 2013)

Education:

• Teach G.B to avoid fried foods and foods with high fat content that predisposes her to gallstones formation, and their complications.
• Emphasize on the need of aversion of alcohol since it can cause a severe gastrointestinal upset (Copstead-Kirkhorn & Banasik, 2014).

Non-medication treatments:

Lifestyle change such as cessation of alcohol consumption, and healthy habits like exercising and eating of balanced diet (Hinkle, Brunner, Cheever, & Suddarth, 2014)

Follow up: Refer to a gastroenterology specialist for review and remind patient to seek medical assistance if her symptoms persist.