The SOAP note details the history and examination of JR a 47-year-old white male with complains of persistent abdominal pain and diarrhea. Physical examination reveals left lower quadrant and hyperactive bowel movements indicative of a possible gastroenteritis diagnosis. This paper will analyze the subjective and objective details of the SOAP note.
JR had two major complains but only one of them (abdominal pain) was discussed in details. The patient was to be probed on the frequency of the diarrhea, the volume and consistency, the color, presence of blood stains and any accompanying symptoms such as thirst, dry mucous membranes and decreased urine output which could be indicative of dehydration(Meisenheimer et al., 2022).Other additional symptoms such as fever, vomiting or nausea should be ruled out. In the past medical history, the year of onset of the chronic illnesses should be included. The social history should quantify the social drinking and the type of alcohol taken. Review of systems could also be essential in ruling out other diseases.
The objective data given does not reveal the general JR. It should include the patients’ general appearance, if he is in distress, obvious pain, appears dehydrated, pale, cyanosed, jaundiced or edematous. Physical examination of the affected system should have been thorough where examination details on inspection could have included the symmetry, scars, distention or any visible vessels. On palpation masses, organomegally, guarding and tenderness should be ruled out. The percussion should also be noted. It is important to note the rate of bowel sounds (DiLeo Thomas & Henn, 2021).
The assessment findings are supported by both objective and subjective data apart from the fact that the abdominal pain was generalized and not specific as opposed to the physical findings.
The patient could have benefited from laboratory tests such stool for ova and cyst, stool for microscopy, culture and sensitivity and a complete blood count. An abdominal ultrasound could have been vital in probing the cause of the abdominal pain and the left lower quadrant pain.
Pain is not a differential diagnosis but rather a symptom thus the differential diagnosis of left lower quadrant pain does not hold water. It should rather explore some of the conditions that can cause lower quadrant pain such as diverticulitis(Galgano et al., 2019). Others include inflammatory bowel disease and irritable bowel syndrome. Gastroenteritisis supported by the data provided.
The subjective and objective data provided in the case of JR was not as detailed as it is recommended. The patient could have greatly benefited from several laboratory investigations such as stool analysis, complete blood count and even an abdominal ultrasound. From the history the patient is likely to be suffering from acute gastroenteritis which is mostly infective like bacterial, viral, diverticulitis or inflammatory bowel disease.
DiLeo Thomas, L., & Henn, M. C. (2021). Perfecting the Gastrointestinal Physical Exam. Emergency Medicine Clinics of North America, 39(4), 689–702. https://doi.org/10.1016/j.emc.2021.07.004
Galgano, S. J., McNamara, M. M., Peterson, C. M., Kim, D. H., Fowler, K. J., Camacho, M. A., Cash, B. D., Chang, K. J., Feig, B. W., Gage, K. L., Garcia, E. M., Kambadakone, A. R., Levy, A. D., Liu, P. S., Marin, D., Moreno, C., Pietryga, J. A., Smith, M. P., Weinstein, S., & Carucci, L. R. (2019). ACR Appropriateness Criteria® Left Lower Quadrant Pain-Suspected Diverticulitis. Journal of the American College of Radiology, 16(5), S141–S149. https://doi.org/10.1016/j.jacr.2019.02.015