Assignment:Episodic/Focused SOAP Note Template Examples

Assignment:Episodic/Focused SOAP Note Template Examples

Assignment:Episodic/Focused SOAP Note Template Examples

 Patient Information: L.B. 61-year-old male African American

Initials, Age, Sex, Race

S.

CC: Diarrhea

HPI: L.B. a 61-year-old African American male, presents to the clinic today with the report of diarrhea and vomiting intermittently for the last three months. The patient reports a dull aching pain in his lower stomach and rates his pain a five out of ten on the pain scale. He reports that he is “unable to hold anything down.” He states that when he eats, it makes him vomit. The patient reports taking amoxicillin, which seemed to help with the vomiting but never stopped the diarrhea. He also reports weight loss of about 20 pounds over the past three months, that was unintentional. He reports a history of a kidney transplant.

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Current Medications:

Aspirin 81 mg tablet once daily

Atorvastatin 10 mg tablet once daily

Centrum 1 tablet once daily

Glucagon Emergency Kit for hypoglycemic emergency

Hydralazine 25 mg 1 tablet twice daily for hypertension

Isosorbide Dinitrate 20 mg 1 tablet twice daily for hypertension

Lantus 25 units at bedtime for diabetes

Metoprolol Succinate ER 50 mg 1 tablet once daily for heart rate

Mycophenolate Mofetil 250 mg 3 tablets every 12 hours

Pepcid 20 mg tablet 1 tablet once daily for acid reflux

Prednisone 5 mg tablet once daily for organ transplant

Tacrolimus 1 mg 2 tablets twice daily for organ transplant

Zofran 4 mg 1 tablet 3 times a day as needed for vomiting

Allergies:

Denies environmental allergies

Denies food allergies

Denies latex allergies         

PMHx:

Anemia

CKD

Type 2 Diabetes

Hypertension

Hyperlipidemia

Diverticula of the intestine

Tdap- 8/16/2018

Flu- 9/27/2021

Prevnar- 1/18/2023

Covid #1-11/01/21 Covid #2-4/16/2021

Colonoscopy-2/10/2023

Kidney Transplant- 3/18/2006

Cardiac Defibrillator- 3/01/2019

Soc Hx: The patient is a recently retired banker and has a Bachelor’s in Finance. His hobbies are horse riding and watching sports. He is married and has two children 35 and 32 years. He has a history of smoking but stopped in 2004 following acute kidney failure. He stopped taking alcohol more than 10 years ago.

Fam Hx:

Father, who died at age 88, had a history of carcinoma of the prostate.

Mother died at age 79, had a history of hypertension, diabetes, and hyperlipidemia.

Maternal grandmother

Maternal grandfather

Paternal grandfather

Paternal grandmother

ROS:

GENERAL: reports weight loss of 20 pounds, fatigue

HEENT:Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: Reports nausea, vomiting, and diarrhea. Reports dull “achy” pain to lower abdomen. No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES: Denies asthma, hives, eczema, or rhinitis.

O.

Physical exam:

Vital signs: BP- 138/90; RR- 18; Temp-98.42; HR- 94; SPO2- 99%; Height- 5’5; Weight- 209; BMI- 34.8

General: The patient is neat and appropriately dressed. He is in no acute distress. He is alert, oriented, and maintains eye contact.

Cardiovascular: Regular heart rate and rhythm. S1 and S2 heard.

Respiratory: Smooth and even respirations. Lungs clear bilaterally.

GI: A round stomach with regular movements on respiration; No peristaltic movements are visible; Bowel sounds are hyperactive in all quadrants; Slight lower abdominal tenderness on palpation; No guarding; No masses or organomegaly on palpation and percussion.

Diagnostic results:

1. Stool microscopy for ova and cyst should be performed to identify the cause of diarrhea, that is, viral, bacterial, or protozoal (Orenstein, 2020).
2. Stool culture: To identify three primary bacteria Campylobacter, Salmonella, and Shigella associated with diarrhea (Hiner & Walters, 2021).
3. Complete blood count (CBC): This will help to identify signs of infection based on the white blood cell (WBC) count (Hiner & Walters, 2021).
4. Abdominal ultrasonography: To identify if the patient has an inflammation of the abdominal organs, which often causes abdominal pain, nausea, and diarrhea (Hiner & Walters, 2021).
5. A.

Differential Diagnoses

1. Irritable Bowel Syndrome (IBS) (K58. 8): IBS is characterized by chronically abnormal bowel habits (diarrhea or constipation) associated with abdominal pain. The symptoms include crampy lower abdominal pain and abdominal bloating/distention with associated constipation, diarrhea, or alternating diarrhea and constipation. Other symptoms include Nausea, vomiting, heartburn, anorexia/ weight loss, fatigue, and urinary symptoms. This is the primary diagnosis based on positive symptoms of lower abdominal pain, chronic diarrhea, nausea, vomiting, weight loss, fatigue, and dysuria.
2. Inflammatory Bowel Disease (IBD) ( 90): IBD has two types: Ulcerative colitis (UC) characterized by inflammation in the colonic mucosa. Crohn’s disease is characterized by inflammation in any segment of the GI tract from the mouth to the anus. IBD is a differential due to symptoms of lower abdominal pain, irregular bowel patterns (diarrhea), and weight loss (Włodarczyk et al., 2021). Nausea and vomiting can be attributed to Crohn’s disease.
3. Gastroenteritis (GE) (A09): GE is a differential based on symptoms of abdominal pain, nausea, vomiting, and diarrhea. However, the patient has had diarrhea, and vomiting for a prolonged period, which rules out GE since it is a self-limited disease (Farmer et al., 2020).
4. Lactose Intolerance (E73): Lactose intolerance presents with nausea, abdominal pain, abdominal bloating, loose stools, and flatulence (Facioni et al., 2020). It is thus a differential based on patient symptoms of abdominal pain, nausea, and diarrhea.

P.

1. IBS

Diagnostic tests: Stool exam to assess for ova and parasites, pathogens, and leukocytes.

Referrals: Refer to a gastroenterologist if symptoms do not improve with treatment.

Therapeutic interventions: Loperamide (2-4 mg) taken before meals. The loperamide dose will be increased to minimize diarrhea while avoiding constipation (Cangemi & Lacy, 2019).

Rifaximin 550 mg orally TDS for 14 days. This is an antibiotic established to alleviate bloating and abdominal pain and improve diarrhea.

Education: Education on dietary measures including eating small regular meals rather than large meals and eating in a slow and paced manner. A low-fat diet will be recommended to minimize postprandial GI symptoms (Cangemi & Lacy, 2019).  

Follow-up: Follow-up after two weeks to assess symptom improvement.

2: IBD

Diagnostic tests: Diagnostic tests needed to confirm or rule out IBD include CBC, Erythrocyte sedimentation rate, and C-reactive protein levels (Hellström, 2019).

Referrals: Refer to a gastroenterologist.

Therapeutic interventions: Sulfasalazine 0.5 g orally BD. Take with food (Włodarczyk et al., 2021)..  

Education: Education and diet and stress management to prevent flares.

Follow-up: Follow-up after 2 weeks.

3. 3. GE

Diagnostic tests: Stool microscopy for ova and parasite (Hiner & Walters, 2021).

Referrals: Consult a gastroenterologist and infectious disease specialist.

Therapeutic interventions: IV Rehydration with Saline and Lactate (Hiner & Walters, 2021).

 An antibiotic for bacterial GE, Cefixime 400 mg PO once daily.

Education: Measures to prevent water and food contamination like avoidance of undercooked meats and seafood. Hand hygiene and food hygiene practices.

Follow-up: Follow-up after one week.

4. Lactose Intolerance

Diagnostic tests: A Milk tolerance test will be required to confirm or rule out the diagnosis (Hellström, 2019).

Referrals: Refer to a gastroenterologist and a nutritionist to guide management.

Therapeutic interventions: Calcium and Vitamin D supplements.

Education: Dietary adjustment by reducing or restricting products containing lactose (Facioni et al., 2020).

Follow-up: Follow-up after 2 weeks.

Reflection

I agree with the preceptor’s primary diagnosis of Irritable Bowel Syndrome and the treatment plan. The patient had a functional GI disorder that resulted in chronic diarrhea and abdominal pain, alongside other GI symptoms. I learned that antibiotics and antidiarrheal agents are recommended for patients with diarrhea-predominant IBS. In a different case, I would assess for psychological distress, which is common among patients with IBS. Health promotion should focus on dietary interventions, which should align with the patient’s ability to afford the recommended foods and availability.

References

Cangemi, D. J., & Lacy, B. E. (2019). Management of irritable bowel syndrome with diarrhea: a review of nonpharmacological and pharmacological interventions. Therapeutic advances in gastroenterology, 12, 1756284819878950. https://doi.org/10.1177/1756284819878950

Facioni, M. S., Raspini, B., Pivari, F., Dogliotti, E., & Cena, H. (2020). Nutritional management of lactose intolerance: the importance of diet and food labeling. Journal of translational medicine, 18(1), 260. https://doi.org/10.1186/s12967-020-02429-2

Farmer, A. D., Wood, E., & Ruffle, J. K. (2020). An approach to the care of patients with irritable bowel syndrome. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 192(11), E275–E282. https://doi.org/10.1503/cmaj.190716

Hellström, P. M. (2019). Pathophysiology of the irritable bowel syndrome – Reflections of today. Best practice & research. Clinical gastroenterology, 40-41, 101620. https://doi.org/10.1016/j.bpg.2019.05.007

Hiner, G. E., & Walters, J. R. (2021). A practical approach to the patient with chronic diarrhea. Clinical medicine (London, England), 21(2), 124–126. https://doi.org/10.7861/clinmed.2021-0028

Orenstein, R. (2020). Gastroenteritis, Viral. Encyclopedia of Gastroenterology, 652–657. https://doi.org/10.1016/B978-0-12-801238-3.65973-1

Włodarczyk, J., Waśniewska, A., Fichna, J., Dziki, A., Dziki, Ł., & Włodarczyk, M. (2021). Current Overview on Clinical Management of Chronic Constipation. Journal of clinical medicine, 10(8), 1738. https://doi.org/10.3390/jcm10081738

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Please fill in the information on social history, family history, and the titles under O, A, and P.

Please ensure that there is 1 primary diagnosis with the ICD code and 3 differential diagnoses with the ICD code. The primary/differential diagnosis should be formulated from the information provided in the HPI. Make sure with each diagnostic test there is supporting data (references). Some of the lab work is already listed.

Please ensure that references are from 2018-current and in 7th edition APA format

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