Summary NR 509 Week 5 Abdominal Pain SOAP Note

NR 509 Week 5 Abdominal Pain SOAP Note (NR 509 Week 5 Abdominal Pain SOAP Note ) S: Subjective – Information the patient or patient representative told you 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. A: Assessment – Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis. 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. Provide a rationale and evidence-based in-text citation for each intervention. NR 509 Week 5 Abdominal Pain SOAP Note

SOAP Note Template

Initials: E.P. Age: 78 Gender: Female

Height Weight BP HR RR Temp SPO2 Pain Allergies

5’ 2 120lbs 110/

70

92 16 37.0C 99% Medication: NKDA

Food: Denies

Environment: Latex (itchy skin rash) dx at age 54

 History of Present Illness (HPI)

Chief Complaint (CC) “Belly pain” CC is a BRIEF statement identifying

why the patient is here - in the

patient’s own words - for instance

"headache", NOT "bad headache for 3

days”. Sometimes a patient has more

than one complaint. For example: If

the patient presents with cough and

sore throat, identify which is the CC

and which may be an associated

symptom

Onset 5 days ago

Location Lower abdomen

Duration Constant. Worse when moving or when eating. ( worse 2-3 days)

Characteristics Constant. Dull and crampy. Generalized pain that stays in one place. (Last BM

5 days ago, non- radiating worsedn over 2-3 days) (Add associated char

diarrhea, last BM)

Aggravating Factors Moving or after eating (put how it helped: little help )

Relieving Factors Resting and not moving ( put the degree of improvement what the pain is at

after intervention)

Treatment None (sips of water no help, Anything they did even if tx did not work)

Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Medication

(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time

Used Reason for Use

Accupril (research med side

effect coud be a DDX)

10mg Daily 24 yrs Hypertension

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S: Subjective

Information the patient or patient representative told you

Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,

hospitalizations, and surgeries. Depending on the CC, more info may be needed.

Last Bowel movement 5 days ago. No gastrointestinal history. Menopausal. Reports 3 pregnancies but

Last colonoscopy: 10yrs ago reports, results were negative. 2 colonoscopy’s total.

Surgical history includes: Cholecystectomy at age 42 and one C-section at 40 with her last pregnancy. Denies other hospitalizations.

No recent travel outside of USA in last few years. Hx: Stomach virus a few years ago for 24hrs. Last flu vaccine 2 years ago. Refuses flu vaccine at

this visit. Unable to recall date of last tetanus but states is currently up to date at this time.

Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent

data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

( add if pt is happy? , add sexual history with BF, ) Born SF, grew up in Korean towen. Widow married 50 yrs. Jennifer lawyer, tim son director.

Retired nurse working at a rehabilitation clinic. Hobbies include gardening, walking a lot. Water aerobics 2-3 times a week. Started Pilates recently

for exercise. Lives with daughter Jennifer with good relationship, daughter is driver. Widow but has a significant other. Denies history or present

tobacco use. Reports first alcoholic drink on 13th birthday. Drinks one glass of white wine every Sunday filled in a normal glass of wine. Avoids

caffeinated drinks but ocassinally has chamomille tea.

-Reports only drinking 2 glasses of water daily, reports typical meal is toast or banana or peach for breakfast, skips lunch, and dinner is a protein

with rice. Reports vegetable intake every other day. Reports usually has a bowel movement every day or every other day. Reports diarrhea episode

prior to being constipated for the last 5 days. ( ask depression, 24hr diet recall, enjoys food in her culture.)

Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for

death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if

pertinent.

Father:Deceased at age 82, obesity, hx Heartburn, HTN, hypercholesterolemia

Mother:Deceased at 88, hx of HTN and DM 2.

Maternal grandparents: CAD, DM2, HTN

Paternal grandparents: hx obesity, CVA , HTN

Husband:passed away at 82 yrs old from a fall, resulting in brain hemorrhage

Brother(Christopher)81yr old – prostate cancer, HTN, hypercholesterolemia.

Brother (Michael) 80 -HTN

Daughter ( Jennifer)-age 46- healthy

Son 48- healthy (Add if history of colon cancer? Denies family colon ca history.)

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.

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