Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example
After reviewing the selected SOAP Note of Patient JR, a 47-year-old white man assessed for abdominal pain, I have determined that the provider should have collected additional history in the present history illness (PHI) with a specific focus on the pain using mnemonic SOCRATES. It is important to ask the patient about the site of the pain carefully, noting whether he uses a single finger or is more diffuse. Next is the origin by enquiring when it started together with whether the onset was sudden or gradual. Let the patient describe the character of the pain using terms like gripping, stabbing, or burning, amongst other times. After getting the character description, two other aspects of the pain are radiation and associations, meaning whether there is radiation, for example, towards the back and expounding on whether it is associated with other signs and symptoms. The provider should then narrow down on the time course, enquiring whether the pain is continuous or intermittent and probing the patient on the exacerbating factors like movement, food, position, or medication and what factors relieve the pain. Lastly, the provider should ask the patient about the severity of the pain using a scale of 1to 10, where 10 means the worst pain ever.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
Besides assessing the positive pain of the lower left quadrant, another component of the subjective section that the provider should have focused on is making a systematic inquiry on the patient’s appetite questions on whether there are fever symptoms and whether the patient has experienced unexplained weight gain or loss. Other pertinent questions should touch on the bowels like when they were last emptied, ability to pass stool with ease, consistency of stool, and presence of blood, mucus, or melaena. Lastly, the provider should have enquired whether the patient has any urinary symptoms and recent changes in diet as the change could trigger diarrhea.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
Analysis of Objective Portion of SOAP Note
A well-written SOAP note in the Objection section should include a run-through of a full list of symptoms from major systems taken in head-to-toe format. There should also have a physical examination of all the body systems. The provider should have included a general review of weight loss, appetite change, lumps, bumps, rashes, amongst others. Then HEENT for head, eyes, ears, nose, and throat. The cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal systems. Additional systems are skin, neurologic, psychiatric, endocrine hematologic or lymphatic, and allergic or immunologic.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
The objective section should also include a physical examination of the patient starting with the general condition of the patient, the vital signs before requesting the patient to adequately undress and then systematically examine the abdomen so that that there is an inspection, percussion, palpitation, and auscultation without forgetting to examine his testes and hernia orifices.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
Does subjective and objective information support the assessment?
Both subject and objective information support the assessment. The patient’s primary complaint supports this viewpoint is diarrhea and lower left quadrant pain. These two and other accompanying symptoms are indicative of gastrointestinal causes. However, the provider should rule out that the symptoms are not related to the patient’s comorbidities of diabetes and hypertension. For example, the subjective information may suggest a cause of gastroenteritis, as do the objective information of a low-grade fever at 99.8(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
What diagnostic tests would be appropriate for this case?
Rapid stool test. The presence of rotavirus or norovirus can help diagnose viral gastroenteritis.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
Would you reject/accept the current diagnosis?
I concur with the current diagnosis of gastroenteritis since the patient’s clinical manifestations include a low-grade fever, occasional muscle aches, nausea, vomiting, watery non-bloody diarrhea, and abdominal pain that diffuses towards the left lower quadrant (Schulmutz et al., 2017).(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
Identify three possible conditions that may be considered as a differential diagnosis for this patient
- Gastroenteritis (Confirmed)
The primary symptoms of gastroenteritis include diarrhea, where there is a minimum of three liquid or semi-liquid stool s every 24 hours accompanied by abdominal pain, nausea, and mild fever. Upon taking the patient’s complete history, and since the patient did not have a persistent fever or bloody stool, there was no need to order a stool study test, and gastroenteritis was confirmed (Cardemil et al., 2020).(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
- Diverticulitis (Refuted)
Diverticulitis may, like gastroenteritis, present with nausea, vomiting, abdominal pain, and constipation. However, according to de Dios Díaz-Rosales et al. (2019), the former’s pain is constant and persistent, although it also occurs on the left lower side. It may also present on the lower side, but constipation was used to rule out its diagnosis.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
- Left Inguinal /Femoral hernia (Refuted)
The patient presents with nausea, vomiting, and rapid pulse with sudden worsening pain that could indicate a femoral hernia. However, this diagnosis was ruled out because there is a lump in the groin area and groin discomfort together with a change in skin color around the area (Goethals et al., 2018). As such, these symptoms were used to rule out femoral hernia diagnosis.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
Cardemil, C. V., O’Leary, S. T., Beaty, B. L., Ivey, K., Lindley, M. C., Kempe, A., … & Hall, A. J. (2020). Primary care physician knowledge, attitudes, and diagnostic testing practices for norovirus and acute gastroenteritis. PloS one, 15(1), e0227890.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
de Dios Díaz-Rosales, J., Salva, C. R., & Velázquez-Meraz, I. (2019). Right side diverticulitis, differential diagnosis of complicated appendicitis. Clinical case. Cirujano General, 41(3), 226-229.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)
Goethals, A., Azmat, C. E., & Adams, C. T. (2018). Femoral hernia.
Schmutz, C., Bless, P. J., Mäusezahl, D., Jost, M., & Mäusezahl-Feuz, M. (2017). Acute gastroenteritis in primary care: a longitudinal study in the Swiss Sentinel Surveillance Network, Sentinella. Infection, 45(6), 811-824.(Analyzing the Subjective Portion of SOAP Note Comprehensive Nursing Essay Example)