Maggie Smith- Abdominal Pain SOAP Note assignment

Maggie Smith- Abdominal Pain SOAP Note assignment

Case Study Video Assignment  #2

Maggie Smith- Abdominal Pain

Students will watch the video and:

  1. Complete the SOAP documentation.
  2. Describe 3 of the most plausible differential diagnosis. Rule-in and Rule-out each diagnosis.  Example: If a patient presents with a painful knee and your top differentials are osteoarthritis, ACL, and Fracture, you would find peer-reviewed Evidence to prove that each of those are possible diagnosis.  For osteoarthritis: Rule in:  What signs and symptoms match what the patient has.  Give the evidence (from peer reviewed based information) to show that the symptoms match.  Then rule out: What is lacking to show this is the actual diagnosis?  You must demonstrate your thoughts with peer reviewed evidence. Maggie Smith- Abdominal Pain SOAP Note assignment.
  3. Complete the Illness script.
  4. Include a reference page

SUBJECTIVE:

CC-

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HPI –

  • Onset –
  • Location-
  • Duration –
  • Character –
  • Aggravating factors –
  • Alleviating factors –
  • Radiation –
  • Timing –
  • Severity –

 

PMH –

Medications – Past –

FH

ROS:

 

OBJECTIVE DATA

  • .

 

Student expectations:

 

ASSESSMENT

  • Abdominal pain
  • Differentials –

 

PLAN

Complete the Illness script for each differential diagnosis. Case Study Video Assignment #2

Illness Scrip Differentiate #1
Epidemiology
Time Course
Clinical Presentation
Pathophysiology Maggie Smith- Abdominal Pain SOAP Note assignment
Lab
Imaging

 

 

Illness Scrip Differentiate #2
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Lab
Imaging

Case Study Video Assignment #2

Illness Scrip Differentiate #3
Epidemiology
Time Course
Clinical Presentation
Pathophysiology
Lab
Imaging Maggie Smith- Abdominal Pain SOAP Note assignment

 

 

References

 

SOAP Note

 

Name: Roger James                                     Date: 11/17/               Time: 1030

 

DOB: 03\03\1971                                            Sex: M

 

SUBJECTIVE:          (Subjective Part of Note This is what the patient tells you. May or may not be correct)

 

CC–        (Chief complaint should be in patient’s own words)

 

“I am here to establish care and have my medications refilled, but I also have a headache” (or Pt. states that he is “here to establish care and have my medications refilled, and I also have a headache”)

 

HPI(History of Present Illness should address all problems in the cc)

 

45 year old male in office to establish care and have his high blood pressure medications refilled. States to be taking Lisinopril and simvastatin medications as previously prescribed.

Previous provider was Dr. Lynch who does not take the patient’s insurance any longer. When asked about headache, patient states it just started when he was in waiting room. Pain scale is about a 2. It does not radiate anywhere and when he takes deep breaths and stretches his neck muscles it gets better. He denies having chronic headaches, but admits to getting them when he is anxious. He has a history of anxiety, but does not take any medications. Maggie Smith- Abdominal Pain SOAP Note assignment.

PMH:

 

Hypertension, Hyperlipidemia, Immunizations: are up to date. Significant childhood illnesses include Mumps age 5 and Measles age 8

 

 

Hypertension Hyperlipidemia

Immunizations: are up to date

 

Significant childhood illnesses include Mumps age 5 and Measles age 8

 

PSH:

 

Appendectomy age 14

 

Treadmill Stress test age 40 for approval of exercise program. Done at Dr. Bickers office with “no problems found”

Medications(Include Name, dosage, route, and schedule if known. Include OTC, Herbs / Supplements also)

 

Lisinopril 20 mg. po BID Simvastatin 20 mg po at bedtime

OTC- Occasional Tylenol 1x per month, No Herbs or supplements

 

Allergies(Include reaction to any allergies)

 

PCN- Reaction is a fine rash. Denies food or seasonal allergies

FM:    (Family History includes grandparents, parents, siblings, and children— and any other blood relatives

 

with significant problems) Maggie Smith- Abdominal Pain SOAP Note assignment.

 

Father: Alive , age 62, has hypertension

 

Mother: Alive, age 62, diagnosed with Breast Cancer 3 months ago, negative for BRCA gene.

Does not know Granparents history and all are deceased. Has no siblings or children.

 

SH:     (Social history is about relationships and life activities)

 

Lives in Amarillo with wife. Has no children. Has a monogamous sexual relationship with wife. Denies any history of tobacco use or illicit drug use. Does drink one to two drinks of alcohol a week. Works as a Paramedic full time. Exercises for at least 30 minutes to 1 hour 3-5 times a week. Does not follow any special diet. Does not have an AD or Living Will. Offered information on and patient declined. Maggie Smith- Abdominal Pain SOAP Note assignment.

ROS: ( Review of Systems is a quick overview of any other issues that the patient may have.)

 

General- denies any fever, chills, malaise, denies pain or discomfort, no distress noted Skin: denies any lesions or rashes

Eyes: denies any eye pain, denies any itching or watery eyes, denies any eye discomfort. Uses glasses and sees opthamologist yearly.

Ears: denies any ear pain or discharge. Can hear without aides. Nose\Mouth\Throat: denies any discomfort, denies any post nasal drainage and no redness or swelling

Neck: Denies any lumps or bumps in neck. States no difficulty moving neck or swallowing. Denies coughing after swallowing. Maggie Smith- Abdominal Pain SOAP Note assignment.

Cardiovascular: Denies any chest pain, denies any history of heart problems. Denies palpitations.

Respiratory: Denies any shortness of breath, denies wheezing or coughing at present. Has never used an inhaler. Has never had any blood in a cough.

Gastrointestinal: Denies any nausea, vomiting, constipation, or diarrhea recently. Denies abdominal pain. Reports normal bowel movement 1 -2 times daily. No current weight loss or trouble eating.

Genitourinary: Denies any pain upon urination, reports normal urinary stream. Musculoskeletal: Denies any joint pain. Denies any arthralgias or myalgias.

Neurological: Denies any problems with chronic headaches. Denies any numbness or tingling of the extremities.

Psychological: Denies any feelings of sadness or depression. Does have a history of mild anxiety with stressors. Is c/o mild anxiety today and feels that is the cause of his headache. Denies ever being treated with medicine for anxiety. Has never suffered from chest pain, SOB, or hyperventilation with anxiety. Denies anxiety being a chronic problem. Does not interfere with quality of life. Maggie Smith- Abdominal Pain SOAP Note assignment.

OBJECTIVE:    (This is your work and is considered objective.) Case Study Video Assignment #2

Physical Examination

 

Weight- 175 lbs                                                 Height- 5’9 BMI- 25.8 Temp- 97.6, P78, R18, BP 128/80

General appearance: well appearing gentleman in no apparent distress. Appears stated

 

age. Answers questions without hesitation.

 

Skin: skin is clean, dry and intact, no apparent lesions or rashes noted

 

HEENT: Head is normocephalic with no masses or bumps felt. Eyes: PERRLA. Ears:

 

TM clear, gray bilaterally, with no noted exudates, minimal ear wax noted. Nares: negative for any swelling or nasal drainage. Oropharynx: negative for PND, erythema or lesions, good dentition noted, negative for tonsillar swelling or exudate. Maggie Smith- Abdominal Pain SOAP Note assignment.

Neck\Lymphatic: Neck: is supple with good ROM without pain or discomfort, no lymphadenopathy noted upon palpation, negative for thyromegaly or thyroid masses. Cardiovascular: Regular rate and rhythm. S1 and S2 without S3, S4. No murmurs,

gallops, rubs, or clicks noted. Peripheral Pulses +2 bilaterally in radial pulses, and dorsalis pedis pulses. No carotid bruits heard.

Respiratory: Lungs clear to auscultation anteriorly, posteriorly, and bilaterally. Easy

 

respiratory effort with no use of accessory muscles noted.

 

Gastrointestinal: Abdomen soft, no distention noted, bowel sounds active and present in

 

all quadrants, with no masses palpated. No tenderness noted. No hepatosplenomegaly noted. Scar in RLQ well healed.

 

Genitourinary: Normal genitally noted with testicles descended. No inguinal hernias felt.

 

Musculoskeletal: Bilateral equal strength noted in all 4 extremities with full ROM noted.

 

No pain or discomfort with movements of joints, and no joint laxity or crepitus. Gait normal with walking.

Neurological: CNII-XII grossly intact.

 

Psychological: Interacts cooperatively for exam, good eye contact, calm and pleasant

 

affect.

 

Diagnostics: none

 

ASSESSMENT :     (Diagnoses, Differentials, and problems)

 

  1. Annual wellness visit to establish care

 

  1. Hypertension

 

  1. Hyperlipidemia

 

  1. Headache

 

  1. History of mild Anxiety

 

PLAN:             (Pharmacological and non-pharmacological management, diagnostics ordered education,

 

referrals, and follow up)

 

  1. Patient to return to clinic in a.m. for fasting labs. CBC, CMP, and Lipid

 

  1. Lisinopril 20 mg twice daily by mouth for high blood pressure. Patient is to monitor blood pressure at least twice a week and report any consistently high or low
  2. Simvastatin 20 mg once daily at hour of sleep. Will adjust according to lab results

 

  1. Call back if headache does not resolve with OTC Tylenol or Ibuprofen. Pt. feels that headache is simple due to anxiety of

 

  1. Anxiety is a self-diagnosis and patient has never had any treatment for this. Discussed at length with patient and he feels that he does not need any treatment for this problem. Will obtain old records from Dr. Lynch and Dr. Bickers Maggie Smith- Abdominal Pain SOAP Note assignment
  2. Follow-up in clinic in 2 weeks to discuss la

Alternative Assessment and Plan

ASSESSMENT / PLAN:

  1. Annual wellness visit to establish care – Patient to return to clinic in a.m. for fasting labs. CBC, CMP, and Lipid
  2. Hypertension – Lisinopril 20 mg twice daily by mouth for high blood pressure. Patient is to monitor blood pressure at least twice a week and report any consistently high or low readings. Pt. given pamphlet on low salt, low cholesterol
  3. Hyperlipidemia – Continue Simvastatin 20 mg once daily at hour of sleep. Will adjust according to lab results
  4. Headache – Call back if headache does not resolve with OTC Tylenol or

Pt. feels that headache is simple due to anxiety of visit.

  1. History of Anxiety- This is a self diagnosis and patient has never had any treatment for this. Discussed at length with patient and he feels that he does not need any treatment for this
  2. voiced understanding of all instructions and will return in 2 weeks to discuss labs.

Will obtain old records from Dr. Lynch and Dr. Bickers. Maggie Smith- Abdominal Pain SOAP Note assignment

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