Assignment: Episodic/Focus Note: Gastrointestinal Condition

Focused SOAP Checklist

SUBJECTIVE:

Chief Complaint: Did I state briefly in the patient’s own words
History of present illness: Did I write a paragraph in the order of the 7 attributes & did I put the 7 attributes in a concise list in the chart (OLD CART-if you don’t know it, please look it up)
Medications: did I list each medication and reason.
Allergies: Did I include specific reactions to medications, foods, and insects, environmental?
Past Medical History (PMH): Did I list all the patient Illnesses, hospitalizations? Did I Include childhood illnesses
Past Surgical History (PSH): Did I list the dates, indications and types of operations?
OB/GYN History: (if applicable) Obstetric history, menstrual history, methods of contraception and sexual function.

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Personal/Social History: Tobacco use, Alcohol use, Drug use, risky sexual behavior. Patient’s interests, ADL’s IADL’s if applicable. Exercise, eating habits. Pediatrics: school status, parental smoking hx, birth history, school/daycare etc
Immunizations: Did I include Last Tdap, Flu, pneumonia, etc. Pediatrics- (per pediatric schedule for age) HPV if applicable
Family History: Did I list for Parents, Grandparents, siblings, children?
Review of Systems (SUBJECTIVE DATA): Did I include the systems related to my Chief Complaint and chronic conditions? Did I type detailed description? I did NOT use WNL. I was specific in my descriptions (see health assessment textbook). Did I remember this is what the patient says and not what I observed? Did I include the cardiovascular and respiratory system regardless of chief complaint?

Physical Exam: (OBJECTIVE DATA) This is what YOU see/touch/hear/smell

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Did I list the vital signs as the first thing in the objective section? Did I include the BMI for adults? Did I include the percentile for the ht, wt, bp etc for pediatrics?
Did I examine the systems that are pertinent to the CC, HPI, and History. Did I describe what I observed? Did I never use WNL or normal? Did I describe what I observed during the physical exam?
Did I include the systems in a list format?
Did I include cardiovascular and respiratory systems regardless of cc?
Did I delete the systems I did not review?

ASSESSMENT:

Did I put my priority diagnosis in bold for EACH CC?
Did I include at least 3 differentials(DD) after the priority diagnosis for EACH of my CC?
Did I explain what each DD is, use references to explain and tell how you ruled in or ruled out each DD? (AND does your ROS and PE reflect this?)
Did I include a reference citation for each diagnosis under the assessment area?
Are my assessments concise and in a chart format?
Did I put my differential diagnosis in order by priority?
Did I provide a detailed rationale for each diagnosis?

Holistic care:

Did I cover existing diagnoses and whether any changes need to be made?
Did I include needed preventative care based on my patient’s age and risk factors?

PLAN:

Did I include a treatment plan?
Did I address if labs, x-rays, etc. were needed?
Did I include a pharmacological plan and citation for EBP?
Did I include non-pharmacological strategies?
Did I discuss alternative therapies if applicable?
Did I state when the patient needs a follow-up?
Did I indication if any referrals or consultations were necessary or not necessary?
Did I write a rationale based on evidence?
Health Promotion: Did I address this area? Did I state what the patient/ family need to do to promote their health based on the USPTF for adults or Bright Futures for children? Did I document my citations?
Disease Prevention: Did I do these based on recommendations from USPTF for adult’s or Bright Futures for children based on the patient’s age? Did I state what needs to be done to detect disease early…fasting lipid profile, mammography, colonoscopy, immunizations, etc? Did I cite the source?

REFLECTION:

Did I state what I learned from this experience?
Did I state what I would you do differently or if I would do everything the same and the rationale?
Did I state if I either agreed or disagreed with my preceptor based on evidence (and cite references for EBP?
Did I state what I would do if the person was insured versus if the person was not insured? Indicate how this would change your plan.
Did I state the community resources in my area?

APA

Do I have a minimum of 3 scholarly journal articles? (NONE OF WHICH ARE PATIENT EDUCATION SITES THAT I GOOGLED)
Did I use at least 3-4 course resources?
Do I have the paper in a neat format?
Did I list my references in APA format?

Developed by Joyce Turner, NP. Revision 2/22/17 by Nancy Hadley, DNP, APRN, FNP-BC

A Sample Of This Assignment Written By One Of Our Top-rated Writers

Assignment: Episodic/Focus Note: Gastrointestinal Condition

Patient Information:

Initials: R.T., Age-17 years, Sex- Male, Race- White

CC (chief complaint): “Abdominal pain.”

HPI: R.T. is a 17-year-old White male who presents to the clinic accompanied by his mother with a chief complaint of abdominal pain. He reports that the abdominal pain started about five days ago. The pain is generalized and described as frequent daily abdominal stabbing pain. The abdominal pain is accompanied by nausea, vomiting, diarrhea, and unintentional weight loss. The pain worsens after eating and has no specific relieving factors. He rates the abdominal at 10/10.

The patient was previously seen by a GI doctor. He was advised to keep a food journal, but he has not. He had an abdomen CT scan and gastric emptying scan that revealed no abnormal findings. According to the mother, the GI doctor suggested that anxiety may be the cause of the abdominal symptoms.

Current Medications: Zofran 4mg PRN PO for nausea and vomiting.

Allergies: Allergic to dust, pollen, and dust mites. No food or drug allergies.

PMHx: History of asthma diagnosed at 6 years. Immunizations are up-to-date. No history of surgery.

Soc Hx: R.T. is in 12^th grade and his school performance has declined in the past months. He lives with his mother and two younger siblings 13 and 8 years. His father separated from his mother when four years ago, but he visits him on weekends. His hobbies are playing video games and drawing. He belongs to the drawing club in his school and has won several drawing competitions. He is also part of the school’s basketball team. He denies ever taking alcohol, smoking, or using illicit substances.

Fam Hx: Great paternal grandmother died from lung cancer. The maternal grandmother had diabetes and heart failure. The parents are alive and well.

ROS:

GENERAL: Reports unintentional weight loss. No chills or fatigue.

HEENT: Reports Blurred vision. Wears corrective lenses. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest Pain, Orthopnea, or Shortness of Breath.

RESPIRATORY: No Chest Congestion, Cough, Excessive sputum, Shortness of Breath, or Wheezing.

GASTROINTESTINAL: Positive for Abdominal Pain, diarrhea, nausea, and vomiting. No Blood in the Stool.

GENITOURINARY: No urinary symptoms or penile discharge.

NEUROLOGICAL: No history of falls.

MUSCULOSKELETAL: No muscle pain, joint pain, or joint stiffness.

HEMATOLOGIC: no bleeding or bruising.

LYMPHATICS: No enlarged nodes.

PSYCHIATRIC: Positive history of mild anxiety and depression.

ENDOCRINOLOGIC: No excessive sweating, cold or heat intolerance, polyuria, or polydipsia.

ALLERGIES: Positive history of asthma. No history of hives, eczema, or rhinitis.

Physical exam:

General: The patient is pleasant, alert and oriented, well-developed, and malnourished.

Chest: Normal shape and even expansion, no tenderness on the chest wall.

Heart: No tachycardia, normal S1, and S2, no clicks, no rubs, no Gallop sounds, no murmurs.

Lungs: Clear to auscultation bilaterally; no wheezes, rhonchi, or rales; regular breathing rate, and effort.

Abdomen: The abdomen is soft, non-tender, and non-distended. Bowel sounds are present, no guarding or rebound tenderness, and no masses palpated.

Peripheral pulses: Normal (2+) bilaterally.

Neurological: The patient is alert and oriented x 3, muscle strength-5/5, PERRLA.

Psychiatric: GAD-7 screening reveals Mild anxiety scoring 9. PHQ-9 screening reveals mild depression scoring of 6. 3.

Diagnostic results:

Abdomen CT scan- normal

Gastric emptying scan- normal

Differential Diagnoses (list a minimum of three differential diagnoses).

R10.9 (Acute Unspecified abdominal pain): Acute nonspecific abdominal pain is defined as acute abdominal pain lasting less than 7 days, and for which there is no diagnosis after physical examination and baseline investigations (Hoseininejad et al., 2019). In this case, the physical causes of pain have been ruled out and the patient has no positive findings on physical exam. Abdominal CT scan and gastric emptying scan also reveal no abnormalities, leading to a diagnosis of non-specific abdominal pain.

R63.4 (Abnormal weight loss): This is unintentional weight loss that manifests with a patient losing noticeable weight even though they are not trying to lose weight. Gastrointestinal and endocrine conditions are common causes of unintentional weight loss (Perera et al., 2021). This is a differential diagnosis based on the patient’s history of unintentional weight loss.

K273 (Peptic Ulcer Disease): The classic symptom of Peptic ulcer disease (PUD) is a burning, aching hunger-like pain in the epigastric region that often radiates to the back. Other symptoms include vomiting, nausea, constipation, and diarrhea (Narayanan et al., 2018). The patient has stabbing abdominal pain accompanied by nausea, vomiting, and diarrhea. This makes PUD a differential diagnosis.

K90. 4 (Food Intolerance): The most common complaints in patients with food intolerance are nausea, abdominal pain, bloating, abdominal cramping, dyspepsia, and diarrhea (Crowe, 2019). The patient could be intolerant to a particular food owing to positive symptoms of abdominal pain, nausea, vomiting, and diarrhea. However, the diagnosis can only e established if he keeps a food journal.

Diagnostic studies: Request for CBC, CMP, Lipid, TSH, ANA, HIV testing, H. pylori IGG, and IGM.

Therapeutic interventions: Refill Zofran 4mg PO prn

Health education: The patient was advised on dietary changes like cutting down on foods and drinks high in caffeine, fatty foods, and spicy foods. This can help to alleviate abdominal pain and GI symptoms (Hoseininejad et al., 2019).

The patient was recommended to maintain a food journal to help identify if he is intolerant to a specific food (Crowe, 2019).

Consultations: Consult the patient’s GI physician and request the client’s medical records.

Follow-up: The patient was scheduled for a follow-up after two weeks. He was advised that if the symptoms get worse, he should call the office, or if an emergency occurs call 911.

Reflection: I agree with the preceptor’s primary diagnosis of unspecified abdominal pain. This is because the patient’s symptoms could not be supported by physical and diagnostic findings. I also agree with the treatment plan of continuing the patient on Zofran to alleviate nausea and vomiting. It is essential to control vomiting to avoid complications like metabolic alkalosis. In a different situation, I would assess the factors causing the patient’s anxiety and depression and ask if he is being bullied in school. I have learned of the “wait and see” approach used in patients with unspecified abdominal pain (Hoseininejad et al., 2019). Health promotion and disease prevention for this patient should focus on helping the patient identify food that could be causing abdominal discomfort and avoiding them.

References

Crowe, S. E. (2019). Food Allergy Vs Food Intolerance in Patients With Irritable Bowel Syndrome. Gastroenterology & hepatology, 15(1), 38–40.

Hoseininejad, S. M., Jahed, R., Sazgar, M., Jahanian, F., Mousavi, S. J., Montazer, S. H., Asadai, T., & Aminiahidashti, H. (2019). One-Month Follow-Up of Patients with Unspecified Abdominal Pain Referring to the Emergency Department; a Cohort Study. Archives of academic emergency medicine, 7(1), e44.

Narayanan, M., Reddy, K. M., & Marsicano, E. (2018). Peptic Ulcer Disease and Helicobacter pylori infection. Missouri Medicine, 115(3), 219–224.

Perera, L. A. M., Chopra, A., & Shaw, A. L. (2021). Approach to Patients with Unintentional Weight Loss. The Medical Clinics of North America, 105(1), 175–186. https://doi.org/10.1016/j.mcna.2020.08.019

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Assignment: Episodic/Focus Note: Gastrointestinal Condition