Patient’s Name: JR
Patient’s Age: 47 Years
The current work will explore the SOAP of JR (initials) and help to organize the data and information of the patient. Seo et al. (2016) explain that SOAP is an acronym for subjective, objective, assessment, and plan. A healthcare professional takes notes from each of these elements to give clear information to other healthcare personnel. The diagnosis made from the assessment is gastroenteritis but the information provided does not support it. Due to this, there is a need for additional subjective and objective information to conduct a proper and advanced assessment. To rule out any possible diagnosis the nurse should order additional diagnostic testing.
Upon arrival at the health facility, JR mentions, “My stomach hurts, I have diarrhea and nothing seems to help.” The patient also complains of having generalized abdominal pain for the last 3 days and have not swallowed any medication, as he had no idea the best medication to take. On a rate of 10, JR indicated when the pain started, it was approximately 9/10 but the extent of the pain reduces to 5/10. He complains that after eating he feels nauseated but the abdominal pain does not affect swallowing.
In his past medical history, JR has hypertension, diabetes, and a history of GI bleeding for four years. His past medical history renders him to taking several medications including Lisinopril 10mg that treats hypertension, Amlodipine 5 mg hypertension, Metformin 1000mg, which according to Walker et al (2014) controls blood sugars in the blood and Lantus 10 units that is a stat for diabetes treatment. On family history, there is no history of colon cancer, his father has type 2 diabetes mellitus and hypertension while the mother is hypertensive, Hyperlipidemia, and has Gastroesophageal reflux disease.
While explaining his condition, it is clear that JR failed to provide a clear description of the abdominal pain. For example, he states that his stomach hurts rather than mentioning the exact location where the pain was coming from. While explaining about the pain, he should have stated whether the pain was throbbing, stabbing, shooting, aching, cramping, or sharp pain. Other aspects that should have been included while taking the subjective data include the onset of the pain such as what was he doing when the pain started? The health professionals should have enquired about the longevity of the pain after starting, any foods triggering the pains, and any other alleviating factors like defecating or belching.
The vital signs of JR indicate a temperature of 99.8, Blood pressure 160/86, heart rate 16, pulse 92, height 5’10, and a weight of 248lbs. JR regular rate and rhythm had no murmurs. The results of a Computed tomography angiograph indicate that JR has a symmetrical chest wall. In addition, her skin has no urticaria or lesions. However, her abdomen on examination is soft, has hyperactive bowel sounds, and pain in the left lower lobe. Based on the objective data the nurse did not make any diagnosis. I believe the objective information was sufficient as it explored all vital signs. However, none of the observed objective information provided the type of illness. Additionally, the abdomen results require intense examination as it was a complaint from the client on abdominal pain and the soft, hyperactive bowel sounds.
Assessment: Mechanisms likely for this case:
There are other potential causes or signs and symptoms that are similar to that of gastroenteritis that requires ruling out such as short bowel syndrome, coeliac disease, diabetes mellitus, urinary tract infection, inflammatory bowel disease, and Whipple’s disease. In this case study, only three of these differential diagnoses will be explored.
Coeliac disease shares some symptoms with gastroenteritis and it is essential as a nurse to identify any differential diagnosis. Some of the symptoms that gastroenteritis and coeliac disease share include nausea, diarrhea, abdominal pain, and vomiting. In the case study, JR experiences abdominal pains, nausea, and diarrhea. However, although he shares these symptoms, he does not have some of the different symptoms that can differentiate the two conditions. For example, he did not complain of fatigue, arthritis, migraines, seizures, and other major symptoms. Based on these factors, it is evident that JR does not have coeliac disease.
The symptom of diarrhea can lead a nurse to conclude that may be the patient has short bowel syndrome. Tappenden (2014) explains that short bowel syndrome is a malabsorption disorder resulting from a dysfunction of the small intestine. Its primary symptom is diarrhea, which is prevalent in the JR case. However, other symptoms include weight loss, dehydration, and malnutrition. In our case, these other symptoms are absent, thus, ruling out the condition.
This is one of the conditions that require further analysis to identify the diagnosis for JR. The first reason for the need for differential procedures is that diabetes mellitus is a complication of gastroenteritis. Secondly, JR has a familial history of diabetes mellitus, an aspect that should not be ignored. However, the two are tied up, which opens the need for early identification of gastroenteritis. The differential diagnosis is by considering JR familiar history, which means there is a need for taking the blood sugar levels of the patient.
The first step is providing the patient with fluids and advising him to take more fluids to ensure he remains hydrated. This will include prescribing oral rehydration drinks. The nurse will determine the cause of gastroenteritis – is it a bacteria or virus. Medications will be provided depending on the cause. In case it is bacterial, the antibiotic of choice is Ampicillin.
Diagnosing that JR has gastroenteritis requires a thorough assessment.
Krishnan, B. (2013). Gastrointestinal complications of diabetes mellitus. World Journal of Diabetes, 4(3), p.51.
Laurikka, P., Salmi, T., Collin, P., Huhtala, H., Mäki, M., Kaukinen, K. and Kurppa, K. (2016). Gastrointestinal Symptoms in Celiac Disease Patients on a Long-Term Gluten-Free Diet. Nutrients, 8(7), p.429.
Tappenden, K. A. (2014). Pathophysiology of short bowel syndrome: considerations of resected and residual anatomy. Journal of Parenteral and Enteral Nutrition, 38, 14S-22S.
Walker, R. J., Smalls, B. L., Hernandez-Tejada, M. A., Campbell, J. A., & Egede, L. E. (2014). Effect of diabetes self-efficacy on glycemic control, medication adherence, self-care behaviors, and quality of life in a predominantly low-income, minority population. Ethnicity & Seo, J. H., Kong, H. H., Im, S. J., Roh, H., Kim, D. K., Bae, H. O., & Oh, Y. R. (2016). A pilot study on the evaluation of medical student documentation: assessment of SOAP notes. Korean journal of medical education, 28(2), 237.disease, 24(3), 349-355.
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