­­­­3P Courses Shadow Health SOAP Note Template

­­­­3P Courses Shadow Health SOAP Note Template

­­­­3P Courses Shadow Health SOAP Note Template

Subjective

Patient: 

Initials: W.M

Age: 44 years

Sex: Male

Chief Complaint: “Pain in the abdomen.”

History of Present Illness: 

W.M is a 44-year-old White male presenting with a chief complaint of abdominal pain that started two weeks ago. He states that the pain began in the upper abdomen in the epigastric region, and it is now in the right upper quadrant. He describes the abdominal pain as constant and radiates to his right shoulder. The pain lasts for almost seven hours a day. The abdominal pain is associated with fever, nausea, vomiting, belching, and a sensation of abdominal fullness. Besides, the patient reports producing dark urine and clay-colored stools. The patient states that the pain is triggered when he takes a high-fat or large meal. W.M reports taking antacid tablets to relieve the abdominal pain, but they had no impact. He rates the pain as 4/10.

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Past Medical History:  History of Gallstones, diagnosed two years ago.

Past Surgical History:  No history of surgery.

Medications:  OTC Antacids to relieve abdominal pain.

Allergies: No known drug, food, or seasonal allergies.

Immunizations: Immunization is up to date. Last TT-4 years ago; Last Flu shot- 6 months ago; He has received two COVID vaccines.

Family History:  The mother has Type 2 Diabetes and Renal failure. The father has a history of Schizophrenia. The maternal grandmother had Diabetes with foot complications and cataracts. The elder brother has HTN and a history of stroke. Children are alive and well. 

Social History/Risk Factors: W.M is married and lives with his wife and three children aged 18, 15, and 10 years. He has a Bachelor’s degree in Finance and works as a financial consultant in an insurance company. He admits to taking beer 3 to 4 bottles about four days a week but denies smoking or using other illicit substances. His hobbies include playing badminton and horse riding. The patient states that he goes to the gym 2-3 times a week. He denies a history of domestic violence.  

Review of Systems:

General: Positive for fever. Negative for chills, weight changes, changes in appetite, changes in activity tolerance, or fatigue.

Head: Negative for headache, dizziness, or sinus pressure.

Eyes: Denies changes in vision, blurred vision, double vision, eye redness, or excessive tearing. Last eye exam: 3 years ago.

Ears: Negative for changes or difficulty in hearing, ear pain, or discharge.

Nose: Negative for runny nose, nasal congestion, nose bleeds, or loss of smell.

Mouth/Throat: Negative for swallowing difficulty, difficulty chewing, mouth sores or lesions, or cavities. Last dental exam: 4 weeks ago.

Neck: Denies neck stiffness or pain.

Respiratory: Negative for cough, sputum, chest pain, difficulties in breathing, or wheezing.

Cardiovascular: Negative for chest pain, palpitations, dyspnea on exertion, or edema.

GI: Positive for nausea, vomiting, anorexia, belching, flatulence, RUQ pain, indigestion, a sensation of abdominal fullness, and clay-colored stools. Negative for painful defecation, rectal bleeding, or constipation/diarrhea.

GU: Positive for dark urine. Negative for difficult/painful urination or urinary frequency/urgency.

Musculoskeletal: Negative for muscle pain, backaches, joint pain/stiffness, enlarged joints, or difficulties in movement.

Neurological: Negative for headache, black spells, dizziness, fainting, or burning sensations.

Psychiatric: Denies depression, anxiety, insomnia, or suicidal thoughts/ideations.

Skin: Denies rashes, itching, or bruises.

Endocrine: Negative for excessive sweating, heat/cold intolerance, increased urine production, acute thirst, or excessive hunger.

Hem/Lymph: Negative for bleeding or bruising.

Objective

Vital Signs: BP- 118/84; HR- 118; RR-20; Temp- 100.58; SPO2-98%

Ht- 5’4; Wt- 163 lbs.; BMI- 23.1

General: Male adult patient in some degree of distress. He is alert and oriented. The patient is appropriately dressed and neat. He maintains eye contact, and his speech is clear. He has a normal gait and posture.

 Neurological: Muscle strength-5/5; Normal gait and balance; CNs- intact.

HEENT: Head: Symmetrical and atraumatic; Eyes: White sclera, Pink conjunctiva, PERRLA; Ears: Tympanic membranes are transparent and shiny bilaterally; Nose: Midline; Nostrils are patent; Nasal septum is well-aligned; Pink nasal mucosa; Throat: Vascular without swelling, exudates, or lesions.

Neck: Full neck ROM. The trachea is symmetrical and mid-line. The thyroid gland is normal on palpation.

Lymph Nodes: Non-palpable

Respiratory: Smooth and uniform respiratory movements. The chest is clear on auscultation.

Cardiovascular: No edema or neck vein distension. Regular heart rate and rhythm. S1 and S2 are present. No systole or friction rubs.

GI: The abdomen is flat with no scars and has smooth movements on respiration. Normoactive bowel sounds on auscultation. Tenderness in the RUQ with an inspiratory pause was educed during palpation of the RUQ. Rebound tenderness.   

Back: The spine is well-aligned.

Musculoskeletal: Active ROM in all joints. No joint tenderness or stiffness.

Skin: Fair supple skin. Skin turgor is immediate. No rashes, discolorations, or lesions.

Psychiatric (affect, mood): The self-reported mood is anxious, and the affect is broad.

Diagnostic results:

Elevated AST and ALT levels.

Elevated Alkaline phosphatase levels.  

Assessment

Cholecystitis: Cholecystitis is an inflammation of the gallbladder. It presents with episodic or vague pain or discomfort in the upper abdomen that radiates to the right shoulder. A high-fat or large meal triggers the pain. Other clinical manifestations include nausea, vomiting, anorexia, belching, flatulence, dyspepsia, a sensation of abdominal fullness, rebound tenderness, and fever (Giles et al., 2020). Some patients may have jaundice, which presents with dark urine, clay-colored stools, and steatorrhea. Physical exam findings include fever, tachycardia, and tenderness in the RUQ or the epigastric region, often with guarding or rebound (Giles et al., 2020). Cholecystitis is a presumptive diagnosis based on pertinent positive findings of RUQ pain and tenderness, fever, nausea, vomiting, belching, indigestion, a sensation of abdominal fullness, dark urine, and clay-colored stools. In addition, inspiratory pause educed during palpation of the RUQ and rebound tenderness point to cholecystitis. The elevated levels of AST, ALT, and Alkaline phosphatase also indicate cholecystitis.

Biliary Disease: Biliary disease is diverse among patients, with some patients having no symptoms and others having signs and symptoms of different severity and combination. Clinical manifestations include upper abdominal pain, jaundice, pruritus, fatigue, weight loss, fatty food intolerance, belching, bloating, and dyspepsia (Younossi et al., 2019). Biliary Disease is a differential diagnosis based on the patient’s history of Gallstones. Symptoms suggesting Biliary disease include upper abdominal pain, belching, flatulence, dark urine, and clay-colored stools.

Acute Gastritis:  Acute gastritis is characterized by inflammation of the gastric mucosa lining. Clinical manifestations of Acute Gastritis include nausea, vomiting, anorexia, heartburn, abrupt onset of epigastric pain or discomfort, hematemesis, and gastric hemorrhage (Rugge et al., 2020). Acute Gastritis is a differential diagnosis based on the patient’s upper abdominal pain, nausea, and vomiting symptoms. However, the presence of radiating RUQ pain rules out Acute Gastritis as the primary diagnosis.

Plan

Further diagnostic testing:  Abdominal U/S to visualize the gallbladder.

Pharmacological treatment:

1. Levofloxacin 500 mg PO once daily. To provide coverage against the most common organisms causing cholecystitis (Mou et al., 2019).
2. Metronidazole 500 mg PO twice daily. To provide coverage against the most common organisms causing cholecystitis.

• Promethazine 12.5 mg QID PRN to control nausea and prevent fluid and electrolyte disorders (Mou et al., 2019).

1. Percocet (oxycodone/acetaminophen) 5mg/325mg PO to provide pain relief. The drug combination is recommended to relieve moderate to severe pain (Mou et al., 2019).

Non-pharmacological Therapy: The initial non-pharmacologic therapy will include bowel rest, intravenous hydration, and correcting electrolyte abnormalities with IV fluids.

Laparoscopic cholecystectomy is recommended first-line treatment for cholecystitis (Mou et al., 2019).

Referral: Referral to a gastroenterologist to plan surgery for the patient.

Patient Education: Patient education will focus more on discharge education in the post-operative phase (Mou et al., 2019). The patient will be informed of possible intolerance to greasy food, which may cause bloating or diarrhea.

Follow-up:  Scheduled follow-up two weeks after discharge to assess the patient’s progress after surgery and any post-surgical complications.

References

Giles, A. E., Godzisz, S., Nenshi, R., Forbes, S., Farrokhyar, F., Lee, J., & Eskicioglu, C. (2020). Diagnosis and management of acute cholecystitis: a single-centre audit of guideline adherence and patient outcomes. Canadian journal of surgery. Journal canadien de chirurgie, 63(3), E241–E249. https://doi.org/10.1503/cjs.002719

Mou, D., Tesfasilassie, T., Hirji, S., & Ashley, S. W. (2019). Advances in the management of acute cholecystitis. Annals of gastroenterological surgery, 3(3), 247–253. https://doi.org/10.1002/ags3.12240

Rugge, M., Sugano, K., Sacchi, D., Sbaraglia, M., & Malfertheiner, P. (2020). Gastritis: An Update in 2020. Current Treatment Options in Gastroenterology, 18(3), 488-503. https://doi.org/10.1007/s11938-020-00298-8

Younossi, Z. M., Bernstein, D., Shiffman, M. L., Kwo, P., Kim, W. R., Kowdley, K. V., & Jacobson, I. M. (2019). Diagnosis and Management of Primary Biliary Cholangitis. The American journal of gastroenterology, 114(1), 48–63. https://doi.org/10.1038/s41395-018-0390-3

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Assessment Description
Using the condition you posted about in DQ 1 this week, provide a SOAP note using the format outlined below. Support your summary and recommendations plan with a minimum of two APRN-approved scholarly resources. You may not select a condition or disorder that has already been profiled by another learner; you must select a different one.

Subjective

CC (Chief complaint)
HPT (History of present illness)
History (Pertinent medical, surgical, social, medications, exposure, family history, allergies, vaccines)
ROS (Review of systems)
Objective

Vital signs/BMI
Physical exam findings
Diagnostic results (include actual “results” or “findings” that you would expect for a certain scenario)
Assessment/Plan

Differential list and rationale for final/working diagnosis
Problem list
Plan for Each Problem

Based on evidence with proper references
Further diagnostic testing you would order
Nonpharmacologic therapy
Pharmacologic therapy, including specific medication dose
Frequency and duration of therapy
Patient education
Follow-up

PLEASE WRITE A SOAP NOTE FOR THE FOLLOWING CHOLECYSTITIS