Question

A 37 year old WF presents to your clinic with CC of RLQ abd pain that has been present/persistent for 3-4 days; today she says it's so bad that she can't stand up straight and she is guarding her RLQ. When she walks into the clinic, her hips are flexed and she is bent over, holding her RLQ. She has had fever for a couple days, she says, and tylenol and ibuprofen aren't helping with the pain or with the fever. She says she has been vomiting persistently since yesterday, hasn't been able to keep anything down and now is vomiting a greenish thin clear liquid that "tastes really bad." NKDA, no medical problems, no daily medications. G9T5P0A4L5. Unsure when she had her last normal menstrual period, states that "I don't really keep up with that anymore." Refuses to answer many questions about her sexual history. States, "I just want you to do something about this pain!" No previous surgical history, unsure when she had her last pelvic exam/Pap smear, denies that she has ever had a mammogram. She smokes 2 ppd cigarettes and has since she was 13 years old. Admits to regular marijuana use and methamphetamines "only on the weekends," admits to ETOH on the weekends too, usually about 12 beers/weekend.

VS: T101.4 oral, HR 117, BP 98/60, RR 25, O2 sat 95% on RA, height 66", weight 115#.

QUESTION: Write a SOAP note base on the information presented above.

Answer 1

Answers :

SOAP Note :

Subjective data:

• Patient complaints of right lower quadrant pain3-4 days,not able to stand straight.
• Fever for 2 days on (Tylenol, ibubrofen taken not relieved)
• Greenish thin vomiting persistantly from yesterday.

Objective data:

• · On observation patient is with severe pain in right lower quadrant,patient hip flexed and bend over,holding the right lower quadrant of abdomen.
• · Refuses to answer many questions
• · Vital signs VS: Temperature-101.4 oral,
• · HR- 117per min
• · BP -98/60mmhg
• · Respiration rate- 25 breath per min
• · O2 sat 95% on RA
• · Height 66"
• · Weight 115#

Assessment:

• Present medical history: Patient complaints of right lower quadrant pain3-4 days,not able to stand straight.
• Fever for 2 days on (Tylenol, ibubrofen taken not relieved)
• Greenish thin vomiting persistantly from yesterday.
• Past medical history: no medical problems, no daily medications.
• Past surgical history:No previous surgical history
• History of substance abuse: She smokes 2 ppd cigarettes and has since she was 13 years old. Admits to regular marijuana use and methamphetamines "only on the weekends," admits to ETOH on the weekends too, usually about 12 beers/weekend.
• Sexual history:Refuses to answer many questions about her sexual history.
• Physical examination:RLQ abd pain, she can't stand up straight , she is guarding her RLQ., her hips are flexed and she is bent over, holding her RLQ
• VS: T101.4 oral, HR 117, BP 98/60, RR 25, O2 sat 95% on RA, height 66", weight 115#
• Lab test and imaging studies: unsure when she had her last pelvic exam/Pap smear, denies that she has ever had a mammogram.

Plan of interventions with rationale:

• Assess probable cause of pain.
• We must have a detailed baseline so we not only know how to treat appropriately, but also to know if it has changed.
• Control pain: repositioning, heat/cold, medications (muscle relaxants, analgesics), and so forth (all as clinically appropriate)
• · Patients who are in pain have trouble participating in care, relaxing, sleeping, and healing. Do what is necessary to proactively treat the patient’s pain, and notify the MD as appropriate of changes or an inability to provide adequate relief.
• Assess bowel movements (color, consistency, frequency, amount)
• This will aid the provider in making clinical decisions significantly. It is essential to report bowel movement characteristics and frequency accurately to aid in this important decision making. This also ensure accurate intake and output recording.
• Ensure adequate hydration; may require intravenous fluids
• Patients with abdominal pain may have a diminished appetite, be NPO, or not want to drink fluids. Assess and promote appropriate fluid balance, which may requiring notifying the provider of a decreased oral intake and need for intravenous fluids to maintain fluid balance.
• Assess bowel sounds
• · Essential to know their quality as a baseline and to routinely reassess to detect changes. If a patient had bowel sounds, but now does not, it is essential to detect that and notify the provider, as the patient may not experience any symptoms.
• Facilitate normal bowel patterns
• Abdominal pain can be due to issues with the GI tract. Therefore, it’s essential to proactively address issues like nausea, vomiting, constipation, and diarrhea as clinically appropriate. This can lessen
• Record intake and output
• Patients with abdominal pain may not be taking in appropriate fluids or foods, or their urinary and/or bowel output may be lacking. Accurate I&O is essential for appropriate clinical decision making.
• Prevent infection
• Abdominal pain may have been caused by a pathogen (gastroenteritis, for example). It is essential to promote adequate hand hygiene and infection prevention to prevent the spread to others or preventing the issue from resolving.
• Assess abdominal distention, report changes in size and quality as appropriate.

Differential diagnoses:

Right Lower Quadrant

• Appendicitis
• Leaking aneurysm,
• Regional enteritis
• Meckel’s diverticultitis
• Abdominal wall hematoma
• Incarcerated or strangulated inguinal hernia
• Ureteral calculi
• Endometriosis
• Ruptured ectopic pregnancy
• Twisted ovarian cyst
• Pelvic inflammatory disease