Soap Note Analysis
Subjective portion
The chief complaint gets outlined in a direct speech; the duration and severity of current illness get highlighted precisely. Past medical and family history provides essential information in evaluating possible risk factors contributing to the current problem. Social history is also presented to guide the formulation of a treatment plan in case it is one of the causes. The history provided a general view of the health status, but it is not specific to the abdomen. Additional information that should get added in the subjective section include the location of the pain, any injuries suffered before, the working environment, type of duties, exacerbation factors, relieving factors, and review of all systems. A statement indicating the general condition of the patient is necessary. The diet and nature of the loose stool should also get included.
Objective portion
Vital signs were taken and recorded to provide baseline findings for reference during interventions. The temperature, blood pressure, and the pulse rate are higher than the normal range indicating a severe problem. The results on palpation of the abdomen should get included. Any other tests that got done should get involved too.
Both subjective and objective information is supportive of the assessment. The data accurately indicates the affected systems that need more investigations. The data, together with any diagnostic tests that may be performed, can be used to arrive at the patient’s diagnosis.
Appropriate diagnostic tests
Blood and urine tests are necessary to detect any signs of infection. Liver enzyme tests should also be carried out to rule out any conditions of the liver that can cause abdominal pain. Stool tests will help rule out infection since the patient had diarrhea. CT scan is appropriate to confirm inflammation, its extent, and to offer a guideline during treatment.
The assessment data in the soap note meets the criteria for the diagnosis of diverticulitis that is characterized by severe abdominal pain in the left lower quadrant of the abdomen, fever, nausea, and change in bowel habits. The patient had increased body temperature indicating fever.
Differential Diagnosis
Irritable Bowel Syndrome
Irritable bowel syndrome is an intestinal disorder that mainly affects the large intestines leading to abdominal pains, gases, diarrhea, and constipation. (Chey, Kurlander, & Eswaran, 2015). It affects mostly children with Rome III criteria present. Systemic illness is not evident. The laboratory tests and results from imaging studies indicate no abnormality.
Appendicitis
Appendicitis is the inflammation of the appendix. It is common in young patients. The pain for appendicitis is mainly localized to the right lower quadrant while that of diverticulitis is mainly on the left lower quadrant and less common on the right side. (Bhangu, et al., 2015). CT scan may indicate an increased diameter of more than 6 mm.
Ulcerative colitis
Ulcerative colitis is the inflammation of the inner lining of the intestinal tract, mainly the colon and intestine. It is associated with bloody diarrhea and rectal bleeding. (Baumgart, & Baumgart, 2017). Limited flexible sigmoidoscopy indicates inflammation in its early stages and ulceration when the disease becomes acute.
References
Baumgart, D., & Baumgart, D. C. (2017). Crohn’s disease and ulcerative colitis. Springer.
Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. The Lancet, 386(10000), 1278-1287.
Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: a clinical review. Jama, 313(9), 949-958.
