GI SOAP Note

2 Subjective ID AK is a 41-year-old white female, date of birth (DOB) is 02.18.1981, who presented to the clinic with complaints of abdominal pain, heartburn, vomiting, and fever. She presents to the clinic alone, and the patient is a reliable historian. CC "I have been experiencing stomach pain and intermittent heartburn that make me uncomfortable and seem to be worsening. I vomited profusely last night, and I have had a fever since then….” HPI AK is a 41 y.o. Caucasian female who visits the clinic complaining of abdominal pain described as intense sharp stabbing pain/cramping, heartburn, vomiting, and is febrile. The abdominal pain rating a 7/10 on a scale, and heartburn had persisted over the last 2-3 days, but the fever and vomiting started only last night at around 10 PM. She vomited five times since last night and began experiencing mild low-grade fever and diarrhea. She continues to report that she has had consumed some salad and ice cream together with her family but admitted that no other person had fallen sick at home. PMH The patient perceives herself as an otherwise healthy adult, denying any medical issues. She also denies any prior involvement in vehicular or other accidents, a psychiatric history, or other severe illnesses. Immunizations: She is fully immunized per CDC guidelines and did not get the flu this year. Pt has received her Tdap vaccine in the past three years and received her covid shot back in January 3 of 2021, receiving the second dose in February of 2022, proceeded by the booster in January of 2022. Chronic illness She denies any chronic medical issues in her adulthood Childhood illness Chronic ear glue that required grommets as a small child but grew out of this condition without any complications or issues into prior years and adulthood. Surgeries Adenoidectomy to place tubes in ear canals. Hospitalizations Denies any previous hospitalizations Blood Transfusion: Denies any blood transfusions. Current Medications She denies taking any prescribed or over-the-counter medications for preventive measures to help with maintaining and aiding her health. Allergies The patient denies having any food, drug, or environmental allergies. Social History AK shares that she lives at home with her family, comprising her husband and two children. She practices monogamy with her husband. Her sister lives nearby and, together with her nuclear family, constitutes her social support system. The patient denies being religious and enjoys spending time with her family. 4 Family History The paternal grandmother had breast cancer at the age of 67. The patient denies any medical problems for her biological father, mother, and two sisters, while the medical history of other family members is unknown. Substance Use The patient denies using drugs but says that she occasionally drinks 2-3 glasses of wine, mostly once or twice a week. She has never smoked or partaken in any illicit drug use. Social Determinants of Health AK lives with her family (her husband and two children aged 8 and 10). She works as a receptionist, and her busy work schedule and children's demands mean she rarely finds time for physical activity. She makes homemade meals at least four times a week, often meat and vegetables; she avoids high-calorie meals. ROS General: Pt shares her general sense of well-being with no limitations in activities of daily living and reports that she is not experiencing any fever, chills, night sweats, fatigue, or fluctuations in her weight currently. Eyes: Denies visual limitations, and pt. reports that she does not wear contact or corrective lenses. Head and neck: Denies headaches, head trauma, migraines, and masses in the neck area. headache. Nose: Denies congestion or drainage from nares. Ears: Denies any drainage, pain, or swelling from ear canals and shares that she has no difficulties with hearing. 5 Skin: Denies any change in skin pallor, present rashes, sores developing, changing in moles, significant hair loss, or changes in nail beds, lumps, or bumps; pt. reported that her skin is warm and moist with no dryness. Lungs: Denies productive/unproductive cough, shortness of breath, or wheezing. Throat/Mouth: Denies sores in her mouth/throat, bleeding gums, or issues with swallowing. Cardiovascular: Denies back or chest pain or feeling of fluttering in the chest. Genitourinary: Denies frequent urination during nighttime hours or trouble urinating in general, stating that her urine has no sediment or blood present when voiding. Endocrine: Denies heat or cold intolerance and states that she has no history of diabetes or Gastrointestinal: The patient complains of abdominal pain, mild diarrhea, nausea, and vomiting; she vomited the food she ate the previous night, after which she vomited another three times. The pt described the vomit to be yellowish coloration. Psych/Neuro: Denies having any events related to fainting or experiencing seizures. Musculoskeletal: Denies having any joint pain or leg swelling. Objective Vital Signs: Height – 5’5”; Weight – 138lb; BMI – 23.0; BP – 116/64; Temperature – 99.9; RR – 16; Pain – 7/10 (National Heart, Lung, and Blood Institute, 2022) General: The patient appears pleasant and well composed in the clinic; pt. is alert and oriented to time, place, person, and situation, and she can answer questions when queued appropriately with a sensical speech. She is adequately groomed and dressed and appears to be well-nourished. Pt exhibits a balanced gait when entering the room and appears to have no signs or symptoms of shortness of breath or acute distress provider’s office. 6 Cardiac: S1/2, RRR, no rubs, gallops, or murmurs upon auscultation of chest anterior chest fields; noting pts brachial and radial pulse with an amplitude of +2 with no significant edema. Respiratory: Symmetrical chest expansion during respiration, no exertion during breathing, lobes clear to auscultation bilaterally without any notable adventitious sounds such as rales, wheezing, or rhonchi. Gastrointestinal: No external scars, skin lesions, or abnormalities; slight abdominal distention; bowel sounds in all four quadrants are hyperactive upon auscultation with tympanic throughout abdominal fields; abdomen non-tender with no enlargement of the liver or spleen; moreover, liver, spleen, and kidneys are nonpalpable, no CVA tenderness. No abnormal vascular sounds such as bruits were auscultated over the abdominal aorta, renal, and iliac arteries. Integumentary: Pallor is usual for ethnicity; no erythema or cyanosis noted, no lesions, rashes, discolorations, abnormal growths, or moles. Assessment Differential Diagnoses 1. Irritable Bowel Syndrome (K58.9): Irritable bowel syndrome (IBS) affects the digestive system, often causing symptoms such as constipation, bloating, diarrhea, and abdominal pain (Moayyedi et al., 2017). This patient exhibits these symptoms. 2. Appendicitis (K36): The inflammation of the appendix is often accompanied by symptoms such as abdominal pain, a loss of appetite that is sometimes followed by nausea and vomiting, usually resulting from intestinal obstruction (Petroianu, 2012; Barisik & Bener, 2020). Surgery is the optimal treatment. 7 3. Gastroenteritis (K52): This condition often results in inflammation and irritation of the intestines and stomach lining, causing abdominal cramps, nausea, vomiting, and diarrhea (Barr & Smith, 2014; Luo et al., 2019). It results from bacterial infections that damage gastric and intestinal mucosa. Plan Diagnosis Tests to be done include urinalysis, imaging, and stool culture. Urinalysis will investigate RBC and WBC that might indicate blood and infection in the patient’s urine; it will also reveal if the urine contains bacteria (Vitale & Lockwood, 2020). Stool culture is essential due to prolonged diarrhea, while abdominal radiography will be necessary to exclude foreign bodies or obstructions (Gore & Levine, 2018). Ultrasound is also an essential imaging technique to rule out appendicitis, masses, or abscess. Final Diagnosis The final diagnosis was IBS; urinalysis, imaging, and stool culture rule out appendicitis and gastroenteritis. Therapy Ondansetron 8mg was administered to reduce nausea and dehydration at the clinic. Rehydration Monitoring the patient’s urine output over five (5) days. Patient Education Advise the patient to adhere to fluid intake as tolerable. Observing strict hand hygiene and sanitation. The patient should resume their usual diet at the earliest opportunity. 8 Follow-Up The patient should return to the clinic immediately if the symptoms do not abate. If not, follow-up is in one week, and the patient should call the clinic if they have any questions. Referral The patient does not need any referrals at this point.