NR509_Week_5_Soap_Note
S: Subjective
Information the patient or patient representative told you.
Initials: EP
Age: 78
Gender: Female
Height:
... [Show More] 5’2”
Weight: 120 lbs
BP: 110/70
HR:92
Temp: 37.0 C
SPO2: 99
RR: 16
Pain (1-10): 6
Allergies:
Medication: NKDA
Food: none
Environment: Latex—“itchy rash”
History of Present Illness (HPI)
Chief Complaint (CC): “pain in my belly” and difficulty going to the bathroom
Onset: Constipation 5 days ago with the exception of an episode of was watery diarrhea 3 days ago
Location: “low in abdomen”
Duration: constant x 5 days
Characteristics: dull “crampy” feeling
Aggravating Factors: eating causes bloating and increased pain, physical activity
Relieving Factors: resting helps a little
Treatment: sips of warm water which did not work
States feeling like she needs to “rest more often” due to the pain.
Current Medications
Medication Dosage Frequency Length of Time Used Reason for Use
Accupril
10mg Daily Unknown hypertension
Past Medical History (PMHx)-
Mrs. Park is a pleasant 78-year-old Korean female. She has a history of hypertension and a surgical history that is significant for cholecystectomy and one cesarean section. She is gravida three para three with two living children and one still birth by cesarean section. Her only hospitalizations were for her cholecystectomy, cesarean section and for the births of her other two children. She is unsure of date of last tetanus, immunizations up to date, has not had flu shot this year. Her last colonoscopy was 10 years ago, and the results were normal. She denies a history of constipation. She does not take vitamins or herbal supplements. She denies taking any pain medication. She does not check her blood pressure at home.
Social History (SocHx)-
Mrs. Park was married for fifty years, her husband, Shin died 6 years ago. She is now seeing a “gentleman friend” and is sexually active. She denies the use of contraceptives and state she has never had a sexually transmitted disease. She denies vaginal or anal intercourse but reports that they “touch and have oral sex”. She denies illicit drug use of any kind. She has never smoked and drinks one glass of dry white wine on Sundays only. She stays active with water aerobics, Pilates, walking with friends, and gardening. She lives with her daughter’s family and usually helps with household chores.
Family History (FamHx)-
Mother: deceased at age 88, cause of death CVA with known history of HTN, DM II
Father: deceased at age 82, passed away in his sleep with known history of HTN, hypercholesterolemia, obesity
Maternal grandmother: history of DM II
Maternal grandfather: Died from heart attack with known history of coronary artery disease
Paternal grandmother: HTN, died from cancer
Paternal grandfather: died in his sleep without any known medical history
Siblings:
Brother, 80: HTN, hypercholesterolemia, slow growing prostate CA
Brother, 81: HTN
Son: Healthy age 48
Daughter: Healthy age 46
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.
Constitutional
Check if Positive Symptom Details
x Fatigue States feeling like she needs to rest more frequently but denies fatigue
Weakness
Fever/Chills
Weight Gain
Trouble Sleeping
Night Sweats
Other
Skin: Denies all symptoms
Check if Positive Symptom Details
Itching
Rashes
Nail
Skin Color
Other
HEENT: Denies all symptoms
Check if Positive Symptom Details
Diplopia
Eye Pain
Eye redness
Vision changes
Photophobia
Eye discharge
Eye discharge
Earache
Tinnitus
Vertigo
Hearing Changes
Hoarseness
Sore Throat
Congestion
Rhinorrhea
Other
Respiratory: Denies all symptoms
Check if Positive Symptom Details
Cough
Hemoptysis
Dyspnea
Orthopnea
Pain on Inspiration
Other
Neuro: Denies all symptoms
Check if Positive Symptom Details
Syncope or Lightheadedness
Headache
Numbness
Tingling
Sensation Changes RUE
LUE
RLE
LLE
Speech Deficits
Other
Cardiovascular: Denies all symptoms
Check if Positive Symptom Details
Chest pain
SOB
Exercise Intolerance
Orthopnea
Edema
Murmurs
Palpitations
Faintness
OC Changes
Claudication
PND
Other
MSK: Denies all symptoms
Check if Positive Symptom Details
Pain
Stiffness
Stiffness
Crepitus
Limited ROM RUE
LUE
RLE
LLE
Redness
Misalignment
Other
GI
Check if Positive Symptom Details
Nausea/Vomiting Denies
Dysphasia Denies
x Diarrhea Last bowel movement was an episode of watery diarrhea 3 days ago
X Appetite Change decreased
Heartburn Denies
Blood in Stool Denies
X Abdominal Pain Dull and cramping
X Excessive Flatus Reports more than normal
Food Intolerance Denies
Rectal Bleeding Denies
Other Last colonoscopy 10 years ago, results normal
Typically has bowel movements daily, usually soft and formed
GU
Check if Positive Symptom Details
Urgency Denies
Dysuria Denies
Burning Denies
Hematuria Denies
Polyuria denies
Nocturia denies
Incontinence denies
Other States slightly less urination than normal but thinks it is due to her “drinking less than normal”
PSYCH: Denies all symptoms
Check if Positive Symptom Details
Stress Denies
Anxiety Denies
Depression Denies
Suicidal/Homicidal Ideation
Memory Deficits
Mood Changes denies
Trouble Concentrating
Other:
GYN: Denies all symptoms
Check if Positive Symptom Details
Rash
Discharge Normal
Itching
Irregular Menses
Dysmenorrhea
Foul Odor
Amenorrhea
LMP Menopause onset at age 54
Contraception None
Other: Menopause at age 54
Sexually active with “gentleman friend” but denies vaginal or anal intercourse. Reports that they “have oral sex and ‘touch’
Hematology/Lymphatics: Denies all symptoms
Check if Positive Symptom Details
Anemia
Easy bruising/bleeding
Past Transfusions
Enlarged/tender lymph node(s)
Blood or lymph disorder
Other:
Endocrine: Denies all symptoms for this system
Check if Positive Symptom Details
Abnormal growth
Increased appetite
Increased thirst
Thyroid disorder
Heat/cold intolerance
Excessive sweating
Diabetes
Other:
O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.
Body System Positive Findings Negative Findings
General Patient is well groomed, interactive and cooperative. Face and head are normocephalic and symmetrical
Skin Cheeks are slightly flushed; skin is wrinkled as expected with age, but no tenting is noted. Skin pink, warm, dry, and intact. There is no tenting. Her hair is evenly distributed and grey in color.
HEENT Nasal septum pink and moist, mouth and throat pink and moist, did not inspect ear canal but ears are symmetrical and even
Respiratory
Lungs clear to auscultation throughout, patient in no distress, denies dyspnea
Neuro Alert and oriented, able to follow commands
Cardiovascular Auscultated heart sounds with bell and diaphragm of stethoscope, S1 and S2 noted without evidence of any gallops, murmurs, rubs or clicks. No additional heart sounds noted.
Aorta palpated at 2cm, no lateral pulsation, no bruit with auscultation.
Auscultated Renal, Iliac, and Femoral arteries bilaterally without bruit noted.
No friction rub noted over liver or spleen.
No evidence of any edema noted in lower extremities
Musculoskeletal
Gastrointestinal Dullness was noted over left lower quadrant with percussion
Patient reacted to pain in left lower quadrant upon light and deep palpation with distention noted as well as noted firm oblong mass 2cmx4cm to the LLQ
Pain evidenced by guarding
Fecal mass detected in rectal vault on digital rectal exam. Bowel sounds normoactive in all quadrants with auscultation.
Abdomen is symmetric and flat, 1st horizontal scar noted in right upper abdomen just below right costal margin, 2nd horizontal scar noted approx. 1 cm above pubic girdle
Liver palpated 1cm below tight costal margin with dullness noted. Liver measured 7cm at the midclavicular line. Spleen not palpable, dullness noted over the spleen
With light and deep palpation no tenderness, masses, guarding or distension (RUQ, RLQ, LUQ)
Patient did not react to CVA tenderness.
Digital rectal exam evidenced no hemorrhoids, fissures, or ulcerations noted. Strong sphincter tone was noted.
Genitourinary Bladder not palpable, no distention or tenderness noted.
Kidneys not palpable, no CV tenderness.
Urine clear, dark yellow and normal odor. No nitrites, WBC’s RBC’s or ketones detected; pH 6.5, SG 1.017.
Psychiatric Psychiatric evaluation not performed Patient calm and cooperative,
Gynecological Pelvic exam performed: No inflammation or irritation of vulva, abnormal discharge or bleeding noted, no masses, growths, or tenderness upon palpation.
A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis
.
Diagnosis ICD-10 Code Pertinent Findings
Acute Constipation due to possible Fecal Impaction K59.00 Hard stool noted in rectal vault with digital rectal exam, mass palpated in abdominal left lower quadrant, abdominal pain and cramping reported, no BM x 5 days, passing flatus
Obstruction of the Colon/Bowel Obstruction K56.60 Must rule out bowel obstruction prior to treating patient with laxatives or stool softeners or the patient will be at increased risk of bowel perforation
Abdominal pain, left lower R10.32 Ongoing abdominal pain
P: Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident.
Diagnostics:
Test Rationale/Citation
Abdominal xray series including upright and supine To rule out obstruction
Abdomen/Pelvis CT if xrays do not rule out obstruction
Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.
Drug Dosage Length of Treatment Rationale/Citation
Accupril 1mg PO daily continued Effectively treats this patients HTN
Fleets Enema 1 enema Once, may repeat x1 Treat initial impaction
Any usage of laxatives and stool softeners are contraindicated until obstruction has been ruled out (Mounsey, Raleigh, & Wilson, 2015)
Miralax 1 measured dose PO daily Daily PRN Assist in regulating bowel patterns (Mounsey, Raleigh, & Wilson, 2015)
Referral/Consults:
Referral/Consults: Rationale/Citation
GI for colonoscopy It has been 10 years since her last colonoscopy, she needs to be reevaluated by a GI doctor as colon cancer is the most common cause of obstruction in this patient population (Mounsey, Raleigh, & Wilson, 2015)
Education:
Education Rationale/Citation
Go to the ER if pain suddenly increases, becomes sharp and tearing, or you start vomiting and are unable to keep anything down.
Patient with constipation/possible obstruction, concern is for perforation and complete bowel obstruction
Increase fiber and fluid intake Until xray/CT to diagnose cause of constipation vs obstruction, laxatives including osmotic laxatives are contraindicated (Mounsey, Raleigh, & Wilson, 2015; Epocrates.com)
If patient does not have a bowel obstruction, I would educate to utilize Miralax daily PRN Regulation of bowel patterns to avoid future episodes of constipation. Miralax has fewer side effects than stool softeners and laxatives.
Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.
Follow Up Rationale/Citation
Follow up with PCP in 5-7 days if symptoms do not improve, follow up sooner or go to the ER if pain gets worse
This patient is at higher risk for bowel obstructions and colon cancer based on her age and family history of cancer
References
List references below:
Mounsey, A., Raleigh, M., & Wilson, A. (2015). Management of constipation in older adults. American Family Physician, 92(6), 500–504. Retrieved from https://search-ebscohost-com.chamberlainuniversity.idm.oclc.org/login.aspx?direct=true&db=mdc&AN=26371734&site=eds-live&scope=site [Show Less]