Question

Create a SOAP NOTE WITH THE CASE STUDY PROVIDED. JR is a 47 year old white male complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5 out of 10 today but he has been as much as a 9 out of 10 when it first started. He has been able to eat, with some nausea afterwards.

Analyze the subjective portion of the note. List additional info that should be included in the documentation

What is the possible diagnosis. Identify at least three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature

Answer 1

IN JR CASE STUDY BEFORE MAKING DIAGNOSIS WE CREATE A SOAP NOTE AS UNDER:-

S= SUBJECTIVE DATA:- IT INCLUDES THE INFORMATION OR THE DATA PROVIDED BY THE PATIENT TO THE PHYSICIAN OR THE HISTORY TAKEN BY THE PHYSICIAN FROM THE PATIENT. For example:-

PATIENT JR IS OLD WHITE MALE 47 YEARS OLD CAME TO THE PHYSICIAN AND COMPLAINS OF GENERALIZED ABDOMINAL PAIN STARTED 3 DAYS AGO. HE DESCRIBES THE SEVERITY OF PAIN AS 5 OUT OF 10, WHICH IS PREVIOUSLY 9 OUT OF 10. PATIENT ALSO FEEL NAUSEA AFTERWARDS EATING. HE DIDN'T TAKE ANY MEDICATION YET.

O= OBJECTIVE DATA:- THE INFORMATION OR THE SIGNS OBSERVED AND RECORDED BY THE PHYSICIAN. IT INCLUDES VITAL SIGNS OF PATIENT, LAB INVESTIGATIONS AND THE PHYSICAL EXAMINATION OF PATIENT.

PATIENT FEELS PAIN WHEN PALPATING THE ABDOMINAL REGION. VITALS ARE NORMAL. NO OTHER ABNORMALITY FOUND.

A= ASSESSMENT:- IT INCLUDES THE DIFFERENTIAL DIAGNOSIS BASED ON THE SIGN AND SYMPTOMS OF THE PATIENT UNTIL UNLESS FINAL DIAGNOSIS NOT MADE BY PHYSICIAN THAT IS MAINLY FOCUSED ON THE LAB INVESTIGATIONS.

ACCORDING TO THE HISTORY OF PATIENT SOME OF THE DIFFERENTIAL DIAGNOSIS ARE AS FOLLOWS:-

1. PAIN IN ABDOMEN AND NAUSEA RELATED TO FOOD POISONING OR FOOD ALLERGIES:- IN MANY CASES WHEN PERSON CONSUMES CONTAMINTAED FOOD OR THE FOOD IS NOT CORRECTLY COOK OR STORED IT LEADS TO FOOD POISONING AND WHEN THE PERSON IS NOT AWARE OF ANY FOOD THAT HE IS ALLERGIC TO, IT CAUSES FOOD ALLERGIES IN PATIENT, THEN PATIENT SHOWS SAME SYMPTOMS AS Mr. JR SHOWS LIKE ABDOMINAL PAIN, NAUSEA AFTER EATING. THE PAIN MAY SOMETIMES ELEVATES AFTER EATING.
2. IRRITABLE BOWEL SYNDROME:- IT IS A CHRONIC CONDITION THAT CAN CAUSE BLOATING AND INCREASED GAS AND PATIENT EXPERIENCED ABDOMINAL PAIN AND SOMETIMES NAUSEA AFTER EATING.
3. GALL BLADDER DISEASE:- IN CASE OF GALL BLADDER DISEASE PATENT FEEL SEVERE ABDOMINAL PAIN AND THE BILE SECRETED BY THE GALL BLADDER IS RESPONSIBLE FOR FOOD DIGESTON, SO IN CASE GALL BLADDER DISEASE IMPROPER BILE SECRETION LEADS TO IMPROPER FOOD DIGESTION WHICH CAUSES NAUSEA AFTER EATING.
4. ACUTE PANCREATITIS:- WHEN PANCREAS BECAME INFLAMED OR INJURED IT LEADS TO ABDOMINAL PAIN AND NAUSEA AFTER EATING AND SOMETIMES VOMITING MAY ALSO OCCUR.
5. MESENTRIC ISCHEMIA:- THE ARTERIES IN THE INTESTINE ARE NARROWING AND IT RESTRICTS THE BLOOD FLOW WHICH CAUSES ABDOMINAL PAIN AND NAUSEA AFTER EATING. IT ALSO CAUSES BLOATING AND DIARRHOEA.

P= PLANNING:- IN INCLUDES THE TREATMENT PROVIDED TO PATIENT TO RESOLVE HIS CONCERNS. IT MAY INCLUDE SOME FURTHER LAB TESTS OR ANY EXAMINTAION OR ANY SURGICAL PROCEDURE.

For example:- FROM ABOVE DIFFERENTIAL DIAGNOSIS IF PATIENT IS DIAGNOSED WITH FOOD POISONING THEN TREATMENT WILL BE:

• ADVICE PLENTY OF WATER TO PATIENT.
• ASK TO AVOID CAFFEINE AND ADVICE TO TAKE MEDICATION SUCH AS IMODIUM WHICH SUPPRESS NAUSEA AND RELIEVES PAIN.

IF DIAGNOSE WILL BE ACUTE PANCREATITIS THEN TREATMENT WILL BE:

• ANALGESICS TO RELIEVE PAIN.
• IF CAUSE OF THIS IS BILLARY THEN CHOLECYSTECTOMY IS PERFORMED IN CASE GALL BLADDER HAS STONES.

THUS ACCORING TO DIFFERENT DIAGNOSE PLANNING AND TREATMENT WILL BE DIFFERENT, IT DEPENS ON HOW ACCURATELT YOU MAKE DIAGNOSIS.