Assignment: Nursing soap note on a 72 year-old female with abdominal pain

Assignment: Nursing soap note on a 72 year-old female with abdominal pain

Assignment: Nursing soap note on a 72 year-old female with abdominal pain

Select a patient with a common condition(s) from your practicum experience this week. Submit a correctly formatted SOAP note on that patient in a Word document.

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SOAP NOTE

ID: Rogers Miller, DOB 1/2/1949, a Caucasian male was admitted at the emergency department with abdominal pain.

S

CC: the elderly patient was diagnosed with acute abdominal pain.

HPI: The identified patient is a 72-year old female with noteworthy complaints about abdominal pain. The patient reported constant, severe abdominal pain experienced in the upper left quadrant of her abdomen as well as the right shoulder blade. Accompanied by Nausea, the pain experienced by the identified patient is worsened by eating due to the excessive bloating and gas (Reed & Malik, 2018).  Whilst the use of Rolaids, aspirin and amlodipine proved instrumental in reducing the pain, it persistent nature of the pain requires further intervention. On a likert scale of 10, the patient rates the pain experienced as a 7.

Allergies: No known drug allergies

PHM- no substantial PMH

Childhood:

Surgical:

Medications:

Vaccinations: affirms use of COVID-19 vaccine

Family History: father died of cancer, mother died of diabetes and her younger brother had had his kidney removed 5 years ago.

Social history: Divorced, and living with a domestic helper.

ROS- feart of eating, fatigue, immobility and reduced appetite

General: weight change due to reduced food consumption

Eyes: blurred vision

Ears/Nose/mouth/throat: no hearing problem, infection.

RESPIRATORY: breathing difficulties, persistent shortness of breath, positive for sore throat, running nose

CARDIOVASCULAR: chest discomfort, fever, nausea and chest pains

MUSCUSKELETAL: reports of muscle stiffness, joint pain, back pain, abdominal discomfort

NEUROLOGICAL: headache dizziness, malignancy

PSYCHIATRY: Denies psychiatric history

C/V: affirms mild chest pains, palpitations.

PULMONARY: wheezing, dyspnoea and negative haemoptysis

NEUROLOGICAL: vomiting, constipation, constant focal weakness/numbness, urinary tract infections.

LYMPHATICS: existence of swollen lymph nodes in neck

IMMUNOLOGY: history of seasonal allergies to environmental pollutants and pollen. Affirms frequent illness starting from age 50.

ENDOCRINOLOGIC: reports of heat intolerance

O

Vital Signs BP 125/40     P70 bpm      R 18 breaths      T 99.1 ̊ F

The patient is sociable, accommodative and optimistic.

Skin: pale in colour, and the existence of rashes, lesions and nails with cyanosis.

HEENT:

No Jaundice identified in sclera eyes. No bruits, thyromegaly and nick supple.

Cardiac: no gallops and murmurs. Regular heart rhythm and rate

Pelvic and breast examinations performed by a primary care practitioner in the last 6 months.

Musculoskeletal/ extremities: No clubbing or edema or cyanosis. 2+ dorsalis and radial pulses. Complete range of motion in her hands, shoulders, ankles, knees, elbows without bodily swelling or pain tenderness. The patient is not diagnosed with scapular tenderness (Reed & Malik, 2018).

Flanking and redness between f3-4 and 2-3 toes

Neuro: Gait normal, Romberg normal. Strength 4/4 bilateral lower and upper extremities.

Thorax and lungs: pneumonia, lung inflammation next to the diaphragm

A:

Differential diagnoses: 1. adnominal pain, a possible warning sign of gall stone disease and severe chronic constipation

P:

Less likely possibilities include gastritis, hepatitis, heart disease and/or peptic ulcer illness. The workup will encompass a full blood count, a sonogram of the RUQ         , an EKG and liver chemistries. Constant monitoring and communication with the patient is key throughout the treatment program (Morales, 2018). An assessment of the airway, circulation, breathing, and vital signs is fundamental in responding to a patient with acute abdominal pain. The provision of appropriate and tailored treatment and improved patient outcomes demands a comprehensive analysis of the severity of the disease based on historical facts, physical examination, diagnostic work-up as well as timely consultation with relevant geriatric and/or surgery specialists (Reed & Malik, 2018).

References

Morales, E. A. (2018). Abdominal pain in the elderly: Mini review. MOJ Gerontology & Geriatrics, 2(4). https://doi.org/10.15406/mojgg.2018.03.00131

Reed, A., & Malik, T. M. (2018). Chronic abdominal pain in the elderly: Ischemic pain. Oxford Medicine Online. https://doi.org/10.1093/med/9780190271787.003.0018