Appendicitis SOAP Note – Sample SOAP Solution 1

Appendicitis SOAP Note

Data NeededData for this patient
Patient InitialsV. S.
Identifying Data01012021
Source and ReliabilityAdult Patient
Age18
GenderFemale
OccupationStudent
Marital StatusSingle
Subjective
Chief complaint or appropriate health screening visit: The one or more symptoms or concerns causing the patient to seek care. Need not be the patient’s complete statement – it may be a summary of the reason the patient wanted to be seen for this visit“Pain in my abdomen is getting worse and I can’t stand it any longer”.    
History of Present Illness: Complete subjective description of problem, including “OLDCARTS” findings or similar, including location, quality severity, duration, timing, context, modifying factors, associated signs/symptoms, relieving and aggravating factors, related systems. Medications, including OTC and Herbals PreparationPatient is presenting at the hospital with complaints of worsening and intolerable pain in the abdomen. Appears to be in discomfort with facial grimacing. She rates her pain as 10/10.           O: Last night            L:  Right lower quadrant of the abdomen            D: Continuous             C: Severe abdominal pain with tenderness to the right quadrant, vomiting, and diarrhea            A: Nothing makes it better            R: Nothing            T: None
Past Medical History: Allergies: medications, food, environmental or seasonalChildhood Illnesses: chicken pox, rheumatic fever, rubella, measles, and mumpsAdult Illnesses Injuries Surgeries Hospitalizations Obstetric/Gynecologic Psychiatric Health Maintenance Immunization status: DPT, MMR, influenza, hepatitis, polio, pneumovax, herpes zoster Dental exams (frequency and treatment) Last eye exam (include results) SBE/Pap/GYN (include results) Testicular/rectal exam (include results)PMH:  None PSH:  None Medications: Ibuprofen PRN Allergies: none LMP: July 28, 2022 FMH: Mother (21) deceased, auto accident Father (22) deceased, auto accident            Maternal grandmother (55): alive: no health issues            Maternal grandfather (57): alive: no health issues            Paternal grandmother: unknown            Paternal grandfather: unknown            Siblings: none S.H.:            Sexually active with condoms usage            Tobacco denied            Alcohol denied            Illicit drugs denied            Single            College Student            Freshman            Lives on campus            Daily exercise and a healthy diet            Nine to twelve hours of sleep, stress denied             Wears seat belt             Baptist Immunization:            Last tetanus – 2021            Influenza – 2020            COVID-19 – 2021            Pneumococcal – 2021
Family History: Include presence or absence of specific illnesses in family such as hypertension, diabetes, or cancerFMH: Mother (21) deceased, auto accident Father (22) deceased, auto accident            Maternal grandmother (55): alive: no health issues            Maternal grandfather (57): alive: no health issues            Paternal grandmother: unknown            Paternal grandfather: unknown            Siblings: none
Personal and Social History: Educational levelPersonal interestsLifestyle: exercise and dietOlder Adults: ADLs and iADLsEducational Level: College student Personal Interests: reading novels, writing blogs, and book review. Lifestyle: Daily exercise and healthy diet
Review of Systems:  GeneralEyesEars/Nose/ThroatEndocrineCardiovascularRespiratoryGastrointestinalGenitourinaryHematology/LymphIntegumentaryNeckNeurologicalMusculoskeletalPsychologicalConstitutional: Admits fever, denies chills, fatigue, changes in weight.  HEENT: Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat Cardiac: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.  Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting. G.I.: Admits severe RLQ abdominal pain, nausea and vomiting, and diarrhea.  GU: No report of dysuria or hematuria.  Musculoskeletal:  Denies muscle, back pain, joint pain, or stiffness Skin: No report of rash, lesion, or abrasions.  Neurologic: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Denies difficulties concentrating and paying attention. Endocrine: No reports of cold or heat intolerance. No report of polyuria or polydipsia.  Hematologic: No report of blood clots or easy bleeding. Urinary: Admits frequency, urgency, dysuria Lymphatics: Denies enlarged nodes. No history of splenectomy Allergy: No report of hives or allergic reaction. Reproductive: No report of significant issues. (Females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc…)
Objective
Vital Signs and Measurements Blood pressureTemperaturePulseRespirationsHeightWeightBMI including normal, overweight, obese, morbidly obeseTEMP: 99.2 B/P 125/80 H/R 68 R/R 20 O2 100% R.A. Ht 5’7” Wt 125 BMI 19.6 (within healthy weight range) Pain 10/10
Physical Examination GeneralEyesEars/Nose/ThroatEndocrineCardiovascularRespiratoryGastrointestinalGenitourinaryHematology/LymphIntegumentaryNeckNeurologicalMusculoskeletalPsychologicalGeneral appearance: Alert, oriented X 3, well developed, appears to be in acute distress. Patient complains of severe abdominal pain. HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes. Neck: Supple. No JVD. Trachea midline. No pain, swelling or palpable nodules. Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally. Abdomen:  Symmetric, no lesions, scars, visual mass, bruise, discolor, peristaltic or pulsation are visible, umbilicus is small, inverted, midline, and without signs of herniation. Bowels sounds are present in all quadrants and hyperactive. Abdomen is distended, generalized tenderness with light palpation on lower right quadrant, guarding, no masses palpable, rebound tenderness is noted with deep palpation and quick release (McBurney’s point). Patient complains of severe pain especially in the right lower quadrant. Negative murphy sign. Cardiovascular: Heart sounds audible S1, and S2. Patient’s heartbeat and rhythm are regular. The patient’s heart rate is constant and capillaries refill in two seconds.   Musculoskeletal: Normal range of motion. Regular muscle mass for age. No signs of swelling or joint deformities. Respiratory: Respiration full, even, and unlabored, with symmetrical chest expansion. Bilateral breath sounds clear. Neurological: Balance is stable, gait is normal, posture is erect, tone is good, and speech is clear. Psychiatric: The patient is attentive and cooperative. GU: Costovertebral angle tenderness exam negative  
Assessment and Plan: based on current literature/guidelines. This should be organized and succinct.V.S. is an 18 year old African American female presenting at the hospital with complaints of worsening and intolerable pain in the abdomen.Differential diagnoses including ICD – 10 and Rationale: List the other diagnoses that should be considered in light of the history and physical findings, Articulate a rationale for the most likely diagnosis and for each differential diagnosis. In this discussion, include pertinent positives and pertinent negatives which help to rule out or rule in each diagnosis.Appendicitis (K35.80) Appendix inflammation is referred to as appendicitis. When the opening from the appendix into the cecum becomes blocked, appendicitis is thought to start. Abdominal discomfort is the main sign of appendicitis. At first, the pain is difficult to localize and is diffuse. A second early sign of appendicitis that is frequently present is appetite loss, which can develop into nausea and even vomiting. Later, due to intestinal blockage, nausea and vomiting may also happen. The most typical surgical treatment for abdominal discomfort is for appendicitis. Inflammation of the vermiform appendix, a projection from the apex of the cecum, appendicitis is a medical emergency; the organ must be removed before it ruptures (Hollier, 2018). Patient reports pain in the lower abdomen with tenderness to right quadrant, vomiting and diarrhea making appendicitis the likely diagnosis.   UTI (N39.0) The bladder and its supporting structures are infected with germs in an uncomplicated urinary tract infection (UTI). These patients do not have any comorbid conditions like diabetes, immune system disorders, or pregnancy, nor do they have any structural abnormalities. Lower UTI or cystitis are other names for uncomplicated UTI. Bacteriuria alone does not signify a UTI in the absence of symptoms. Urinary frequency, urgency, suprapubic pain, and dysuria are typical symptoms (Bono et al., 2022). The patient reported increased urinary frequency and urgency and dysuria. However, abdominal discomfort, including rigidity in RLQ, tenderness, and rebound pains qualifies appendicitis as the primary diagnosis.   Ectopic pregnancy (O00) When fetal tissue implants outside of the uterus or connects to an aberrant or scarred area of the uterus, it results in an ectopic pregnancy. If undiagnosed and untreated, ectopic pregnancies have significant risks of morbidity and fatality. When an ectopic pregnancy is present, it may cause pain, vaginal bleeding, or less specific symptoms like nausea and vomiting (Mummert & Gnugnoli, 2022). Right side ectopic pregnancy has almost similar symptoms as appendicitis, including abdominal pain. However, Rigidity in RLQ, tenderness, and rebound pains qualifies appendicitis as the primary diagnosis.  
Most likely diagnosis: (if more than one diagnosis, number each in order of priority) Include: Pathophysiology of the problemExplanation of the diagnosisDiagnostic TestingLab testingRadiology testingCardiac or Neurologic testingEvaluations – Physical Therapy, Occupational Therapy, Speech Therapy, or Mental Health EvaluationsMedications and Treatments – pharmacological and non-pharmacological treatments. Should include at least 2 evidence-based referencesMotivational InterviewingAppendicitis (K35.80) Appendix inflammation is referred to as appendicitis. When the opening from the appendix into the cecum becomes blocked, appendicitis is thought to start. Abdominal discomfort is the main sign of appendicitis. At first, the pain is difficult to localize and is diffuse. A second early sign of appendicitis that is frequently present is appetite loss, which can develop into nausea and even vomiting. Later, due to intestinal blockage, nausea and vomiting may also happen. The most typical surgical treatment for abdominal discomfort is for appendicitis. Inflammation of the vermiform appendix, a projection from the apex of the cecum, appendicitis is a medical emergency; the organ must be removed before it ruptures (Hollier, 2018). Patient complains of severe pain, especially in the right lower quadrant with tenderness, vomiting and diarrhea making appendicitis the likely diagnosis. Diagnostic: CBC and Blood Culture: A complete blood count with differential would indicate an increase WBC Stool Culture: Stool examination and stool culture to check bloody or prolonged diarrhea. Urinalysis: Urinalysis should be performed to determine WBC & RBC which signifies infection and blood in the urine. It also determines the presence of gram-negative bacteria in the urine. CMP: It aids to evaluate dehydration Pharmacologic Management: Preoperative antibiotics may be prescribed by surgeon (Gorter, 2016). Zofran 4mg one-time dose prescribed in the hospital, minimizes nausea and the chance of dehydration.  Nonpharmacologic management:  NPO, refrain from using laxatives, enemas, or heat application to abdomen, prompt surgery is treatment of choice: appendectomy (Gorter, 2016).Rehydrate with small amount of clear liquids every 5-10 minutes and patient is observed in the hospital.Monitor urine output for the next 3-5 days Education: Resume maintenance fluid level as toleratedThe patient should start eating normally as soon as possible. Beginning with a bland diet that includes foods high in refined carbohydrates like bananas, applesauce, pretzels, and rice.Good and frequent hand washing and sanitation techniques. Consultation: Prompt surgical consultation (Craig, 2018). Prevention: There is no proven way to prevent appendicitis (Craig, 2018). Follow-up:  Routine postoperative assessment in 2 weeks, if perforation has occurred antibiotics may be required (Hollier, 2018).
References (APA 7th format)Craig, S. (2018.). Appendicitis. Medscape. Retrieved from https://emedicine.medscape.com/article/773895 Gorter, R. Eker, H., Gorter-Stam, M., Gabor, S. A., Deelder, J. D. (2016). Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. . Surgical Endoscopy, 30(11), 4668-4690. Retrieved from doi: 10.1007/s00464-016-5245-7 Hollier, A. (2018). Clinical Guidelines in Primary Care (3th ed.). Retrieved from http://www.apea.com Mummert, T., & Gnugnoli, D. M. (2022). Ectopic pregnancy. StatPearls [Internet]. Bono, M.J., Leslie, S.W., & Reygaert, W.C. (2022). Urinary Tract Infection. StatPearls [Internet]. StatPearls Publishing.    

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Appendicitis soap note
Appendicitis SOAP Note

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