Soap Note Abdominal (Physical Assessment)

SOAP NOTE Abdominal Physical Assessment S= Subjective Information: Demographics: Patient name Lab Partner is a 40-year-old single female date of birth 02/13/1979, who lives with two roommates in Gwinnett county. Chief of Complaint: Patient states “I started vomiting last night and noticed fever this morning”. She c/o abdominal pain and unable to keep any thing down. History of Present Illness: Patient came to the clinic stating that she started vomiting last night at about 7 pm. She vomited four times and at about 4 am she started with fever and diarrhea. She c/o stomach cramping and unable to keep anything down. She ate soup and salad for dinner with her roommates and states that nobody else is sick at home. Current Health Status: Patient had no known food & drug allergies. Immunizations up to date and yearly physical done in a local clinic regularly. She eats healthy at home and is a nursing student at South College school. She denies getting her flu shot last year. Past Medical History: Patient considers herself a normally healthy adult, she denies any medical problems. She denies any surgeries, blood transfusions and hospitalizations. Patient denies being involved in any accidents, and she denies any psychiatric or any other serious illness. Social History: She lives with two roommates in a five-bedroom house in Gwinnett County. Family and friends are her social support system. She attends a local church with her roommates regularly. She enjoys doing things together with her school mates and she has good problem-solving skills. Family History: Father: Denies any medical problems. Mother: Denies any medical problems. Other members of the family: unknown medical history Review of Symptoms: General: Good sense of well being, no ADL limitations Skin: Skin is warm and moist. Head and neck: Denies any headache or abnormalities Eyes: denies visual problems or wearing any corrective glasses and/or contacts Ears: denies hearing difficulty Nose: denies congestion or difficulty breathing Throat & mouth: denies dysphagia, gingivitis and sores Cardiovascular: denies palpitations, chest or back pain Lungs: denies difficulty in breathing Gastrointestinal: complain of nausea, vomiting, diarrhea and abdominal pain and cramping. Vomited food particles and yellowish colored vomitus about 5 times in the last 24hrs. Diarrhea three times in the last 24 hrs and is foul smelling, yellowish brown in color. Genitourinary: Denies any dysuria, nocturia or frequency Musculoskeletal: extremities optimal functioning, denies any leg swelling and denies any joint pain Neuro/Psych: no fainting, seizures, motor or sensory loss. Endocrine: No known thyroid issues, temperature intolerance, sweating average. No symptoms or history of diabetes. O= Objective Information Vital signs: BP -118/59; PP - 72; RR - 18; T - 98.1; Ht 5’2’;Wt 130lb; BMI 24.0; O2-94; Pain6/10 on a scale of 0 no pain-10 worse pain General: Patient observed to be in her normal state of health includes proper grooming and balance gait. No SOB, nail beds are pink in color with capillary refill of less than two second. HEENT: Head: No deformity noted nor any signs of trauma, normal shape, no bumps & scrapes, healthy hair growth, face symmetrical. Eyes: noted normal vision, conjunctiva clear, with no abnormal drainage. Ears: Bilateral ears normal in appearance, no abnormal drainage, no redness nor swelling noted in the ear canal. Nose: No noted mucus running down from the patient’s nose, normal mucosa, midline septum, no noted sinus tenderness. Throat: normal color with no swelling in appearance and no abnormal drainage noted, no dysphagia noted Neck: Normal to touch, no jugular vein distension. Chest & Back: Symmetrical chest rise with normal chest expansion upon breathing. Respiratory rate is normal with normal depth & pattern. No depression, bulging & crepitus in palpation. No breast nodules. Skin: Brown color with no skin rash, sores & lesions noted. Palms cold and moist with good color. Nails without cyanosis and clubbing. Skin turgor less than 2sec. Gastrointestinal: Abdomen protuberant, bowel sounds hyperactive on all quadrants, no tenderness on palpation. No rebound tenderness noted. Liver edge smooth and palpable 1 cm below right costal margin. Spleen and kidney not felt, and no costovertebral tenderness noted on palpation. Musculoskeletal: No joint deformities and good range of motion noted. A=Assessment: 1. Gastroenteritis Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines. The most common symptoms are nausea, vomiting diarrhea and crampy abdominal pain. It can be caused by various viruses, bacteria and parasites. Bacterial agents cause damage to the intestinal mucosa. 2. Appendicitis Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and poorly localized. A second, common, early symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. Nausea and vomiting also may occur later due to intestinal obstruction. Appendicitis is the source of abdominal pain most commonly treated with surgery. 3. Irritable Bowel Syndrome Irritable bowel syndrome is a disorder that leads to abdominal pain and cramping, changes in bowel movements, and other symptoms such as fullness, gas and alternating diarrhea and constipation. P=Plan: 1. Diagnostic: CBC and Blood Culture: A complete blood count with differential may show an increase WBC Stool Culture: Stool examination and stool culture for bloody or prolonged diarrhea. Urinalysis: Urinalysis should be done to check WBC & RBC which signifies infection and blood in the urine. It also checks the presence of gram-negative bacteria in the urine. CMP: It helps to evaluate dehydration. Imaging: Abdominal radiographs to rule out obstruction or foreign body and ultrasound used to rule out abscess, masses or appendicitis. 2. Therapeutic:  Zofran 4mg one-time dose given in the hospital, reduces nausea and reduces the chance of dehydration.  Rehydrate with small amount of clear liquids every 5-10 minutes and patient is observed in the hospital.  Monitor urine output for the next 3-5 days. 3. Education:  Resume maintenance fluid level as tolerated  Patient should return to a regular diet as soon as possible. Patient could start with bland diet, which includes complex carbohydrates such as bananas, applesauce, pretzels, and rice.  Good hand washing and sanitation techniques. 4. Follow-up: Return to the clinic immediately if worsening of symptoms such as persistent fever, chills, vomiting, diarrhea or signs of dehydration. Otherwise follow up in two weeks and call for any additional questions. 5. Referral: No referral needed at this time.