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Abdominal Pain SOAP Note

Abdominal Pain SOAP Note

Introduction

As an Advanced Practice Nurse you will need to be familiar with all available clinical practice guidelines however, their application will depend upon your ability to critically think and develop differential diagnoses. Each patient encounter will result in a written SOAP note. This week we will dive into abdominal pain, differential diagnoses, and SOAP notes. The SOAP note communicates the plan to the team. The team is interprofessional and includes physicians, APN‘s, nurses, physical therapists, occupational therapists, speech therapists, and consultants. The SOAP note is the universal language. Additionally, the documentation in the note generates the billing level for the encounter. The SOAP note must include the entire plan, likely diagnoses, tests, and treatments.

An 18 year male presents to the office complaining of lower abdominal pain. He has no PMH, no allergies and No Primary Care Provider. Physical exam reveals pain in the ri9ht lower quadrant + Psoas, + Obturator, . Develop a SOAP note remember to include the differential Diagnoses and Diagnostics.

Discussion 1: SOAP Note

Patient Name:

Age: 18 Years

Sex: Male

SUBJECTIVE DATA:

Chief Complaint: The patient presents to the office with complaints of lower abdominal pain.

History of Present Illness: The patient is an 18-year-old male complaining of lower abdominal pain that increases while walking and coughing along with mild fever last night. He also reports a streptococcal pharyngitis one week ago. The pain was vague at the onset, but over the previous 24 hours, it has increased, shifted, and localized over the RLQ. The patient states the pain is excruciating with a 10/10 rating. He denies vomiting but discloses that the pain has radiated into his testicles. The patient is experiencing rigidity due to abdominal muscle spasm, along with nausea and anorexia.

Past Medical History:

Hospitalizations: None

Surgeries: None

Psychiatric Illnesses: None

Chronic Medical Conditions: None

Injuries: None

Family History:

Mother: Type 2 Diabetes

Father: None

Brother: None.

Sister: None.

Social History: Lives at home with parents and does not smoke or drink alcohol.

Additional History: Up-to-date Immunizations

Allergies: None

Medications: None

Health Care Maintenance: No primary care provider.

Review of Symptoms

CONSTITUTIONAL: mild fever, no significant weight gain or loss, chills, fatigue/ malaise.

INTEGUMENTARY:

HAIR: Denies hair loss

NAILS: No abnormalities, no nail discoloration, longitudinal ridges.

SKIN: No skin rashes, wounds, mole, unusual growths, jaundice, bruises, and bleeding.

NEURO: Negative for LOC changes, no tremors, seizures, numbness, weakness, memory lapse/ loss, dizziness, and headaches.

HEENT: HEAD: Denies head injury, or changes LOC; EYES: denies changes in vision, diplopia, and blurry vision. EARS: No hearing loss, drainage pain, ringing, trauma. NOSE: no congestion, nose bleeds, normal sense, and clear nasal drainage. THROAT: No sore throats, hoarseness, difficulty when swallowing, soreness, thrush, bleeding gums, ulcerations, tongue lesions, dentures.

NECK: Negative neck pain, masses, nodules, and no thyroid abnormality.

ENDOCRINE: Denies excessive sweating, hot or cold intolerance, abnormal hunger or thirst appetite, and normal urinary habits.

RESPIRATORY: Denies coughing, sputum, wheezing, recurrent URIs, hemoptysis, bronchitis, pneumonia, and TB history.

GASTROINTESTINAL: Positive right lower abdominal pain with no nausea or vomiting, negative bloating, flatulence, diarrhea, constipation, normal stools, positive for red, and bright rectal bleeding on defecation.

CHEST: No abnormalities, lumps, and nodules

CARDIOVASCULAR: No chest pains, palpitation, orthopnea, claudication, murmurs

MUSCULOSKELETAL: Denies muscular ache, weakness, arthralgia, falls, and balance loss.

GENITOURINARY: Denies, urgency, dysuria, hesitancy, frequency, hematuria, incontinence, nocturia, genital discharge, abnormal bleeding, and STD history

PSYCHIATRIC: No anxiety report from parents, negative for depression, irritability, mood swings, sleep disturbance, and hallucinations.

HEMATOLOGIC:  Negative anemia, bruising, abnormal bleeding, and swollen glands.

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OBJECTIVE DATA

Physical Examination
APPEARANCE: The patient appears well-nourished, pleasant demeanor, co-operative, alert, developed, groomed, clear speech clear, and does not appear distressed.

VITALS: 131/81 (blood pressure), 98 bpm (pulse), oxygen saturation: 99.0% room air, 18.0 rpm (respiration), 98.8 degrees Fahrenheit (temperature), 121 pounds (weight)  5’30” (height) BMI: 21.40.

Pain: 10/10 scale of pain.

NEUROLOGIC: Alert, intact cranial nerves; oriented, Neurologic grossly intact. Sensation intact preserved strength to BUE/BLE, Memory remote, and recent events preserved.

HEENT: Head normal cephalic normal hair distribution. PERRLA and EOMs are intact.  Negative discharge and pain noted. Ears with no tenderness or pain, Sclera clear, Lids normal, Conjunctiva Pink NECK: supple, no masses, Thyromegaly, and JVJ distention.

RESPIRATORY: Normal breath sounds, unlabored respiration, no wheezing, and lungs clear to auscultation.

CARDIOVASCULAR: Normal sinus rhythms, normal S1, and S2, PMI not displaced, negative murmurs, rubs, gallops, bruit, varicose veins, edema, and palpable peripheral pulses in all extremities.

GENITOURINARY: Negative masses visible and no enlarged kidneys

GASTROINTESTINAL: Abdomen tenderness over umbilicus and mid epigastric areas; positive guarding, Psoas, obturator, McBurney’s, and Rovsing’s signs; Negative no masses, scars, herniation, organomegaly, bruits, active bleeding; mild-distend rebound tenderness; bowel sound present all quadrants; and negative thrombosis signs, at RDE.

PSYCHIATRIC: Insight: sound judgment, normal moods, and affect.

MUSCULOSKELETAL: Negative joint effusion, swelling, kyphosis, and scoliosis.

ASSESSMENT

Diagnosis:

Acute appendicitis: Patient clinical presentation and physical exam.

Acute appendicitis (K35.80; ICD 10)

Differential Diagnoses

Crohn disease

Mesenteric adenitis

Gastroenteritis

PLAN

Management

The treatment of acute appendicitis is surgical; thus, once a definitive diagnosis has been made, prompt referral to the surgeon follows.  Preoperative management includes fluid correction and electrolyte imbalance, bed rest, nothing by mouth, placement of the nasogastric tube, and IV antibiotics. The antibiotics of choice are third-generation cephalosporins, antibiotic coverage for anaerobic organisms, and gram-negative aerobic. The antibiotic choices include metronidazole, ampicillin, ampicillin-sulbactam, ticarcillin/clavulanate, gentamicin, and clindamycin.

Patients are discharged on the same day as surgery if there are no complications. Early ambulation with progression to full activity. Diet can be advanced when the bowel sounds return. The male patient is offered standard postoperative guidelines for persons with abdominal surgery.

Follow-up and Referral

The patient is followed by the surgeon, who will be seeing the patient seven days postoperatively and remove his sutures. In case there was an appendix perforation, and the patient was hospitalized, the surgeon follows the patient until he is discharged.

Patient Education

The patient is also given the standard postoperative instructions, including advice to return he develops anorexia, fever, chills, nausea, abdominal pain, and abdominal pain. The patient is also advised not to do the heavy lifting for the next two weeks.

References

Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017). Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Philadelphia, PA: F.A. Davis Company.

Marmo, A. S. (2014). Appendicitis: Risk factors, management strategies, and clinical implications. New York: Nova Biomedical.

Seller, R. H., & Symons, A. B. (2017). Differential Diagnosis of Common Complaints. Philadelphia, Pa, Elsevier/Saunders.

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