Student’s Name:
Institutional Affiliation:
Course:
Instructor’s Name:
Date:
Assessing the Abdomen
SOAP Note
S:
CC: “My stomach hurts, I have diarrhea, and nothing seems to help.”
HPI: M.N, a 47-year-old woman, presents with an abdominal pain complaint that began three days ago. She hasn’t taken any medicines since she didn’t know what to take. She states her pain rate is 5/10 better than it first began.
PMH: Hypertension, Diabetes, GI bleeding history four years back.
Medications: Amlodipine 5 mg, Lisinopril 10mg and Metformin 1000mg.
Allergies: NKDA
Family History: No history of colon cancer, Father has DMT2, Hypertension, Mother as well has HTN, Hyperlipidemia, and GERD
Social: Doesn’t smoke, married with three kids (2 girls and a boy)
O:
Vital signs: Temp 99.8; RR 16; P 92; BP 160/86; Height 5’10”; Weight 248lbs
Heart: No hums
Lungs: Regular chest walls
Skin: Intact without urticaria and lesions
Abdomen: hyperactive bowel reverberations, soft,
Assessment:
Gastroenteritis
Subjective Portion Analysis
The emotional part of the SOAP note helps in analyzing how the patient is feeling. It emphasizes on what patient reports. The subjective part must be systematic, covering a patient’s critical details. Several areas in this soap note have been covered, whereas others haven’t. The covered areas involved chief complaints, history of present disease, past medicinal history, current medications, social history, allergies, and history. Although covered areas helped comprehend the patient’s ailment, the doctor must gather additional information in this particular section. The physician would have collected additional information to provide a complete analysis of the history of the present illness, ask the patient where she was when the symptoms started. The doctor should similarly ask the type of foods the patient had consumed just before the onset of symptoms. The subjective section would as well have emphasized her history of injuries (Colyar 2015). Previous injuries like falling or car accidents may be an aim for current symptoms.
Objective Portion Analysis
The objective part of a SOAP note focuses on the physician’s review. The review should be thorough and should entail a head-to-toe assessment. The objective part of the SOAP focused on the patient’s vital signs, lungs, heart, skin, and abdominal review. Additional information that may be added includes the patient’s overall appearance, general appearance aids in identifying how a patient looks relay to illness. The objective part must similarly contain a review from head to toe. Full body review helps determine the primary diagnosis, and in case the diagnosis is causing the symptoms on numerous body regions. The physician must review the head, nose, eyes, mouth, neck, and chest for the SOAP note. The doctor should similarly assess the patient’s respiratory performance, genitourinary symptoms, neurological and musculoskeletal functioning.
Assessment
The assessment was supported by both the subjective and objective data (Dains, Baumann & Scheibel 2019). Subjective data that supported assessment includes M. Ns chief’s complaint, history of present and past illness, family, and social history. Objective data that supported assessment included an abdominal review that revealed results of LLQ pain. However, the objective analysis was not enough for evaluation as it did not have the laboratory tests and full body review.
Diagnostic Tests
Diagnostic tests suitable for the patient include stool culture to determine parasites, viruses, or bacteria. Endoscopy can as well be used to find the diagnosis. Endoscopy encompasses inserting a camera through the throat to the stomach to check problems like ulcers. A colonoscopy may as well be used to determine intestinal injury or tumors. Colonoscopy inserts a camera through the rectum. Lower gastrointestinal tract radiography may similarly be used to determine intestinal obstructions or the rest of stomach conditions (LeBlond, Brown & DeGowin 2014).
Current Diagnosis
The current diagnosis for the patient is gastroenteritis. This is a condition where the stomach is infected, triggering diarrhea symptoms, vomiting and nausea, and abdominal pain (B&aac
Order this paper