SOAP Note 1

Encounter date: March 17, 2022

Patient Initials: F.P

Gender: Male

Age: 65

Race: White

Ethnicity: Hispanic

Reason for Seeking Health Care

F.P, 65-year-old Hispanic visited the clinic and complained about diarrhea, gas, bloating, severe abdominal pain, and crumpling. The patient admitted having experienced the symptoms in the last month and could hardly work or sleep at night.

HPI

The patient reported that his condition has become worse in the last four weeks. He has been experiencing pain in the lower abdomen. However, the pain decreases after a bowel movement. The patient also reported having frequent and loose stools for over 4 months. F.P reported that gas and bloating have remained the most frustrating symptoms in the last four months. He also reported that the pain sometimes persists after taking solid foods. The patient also reported having had less refreshing night sleep in the last three weeks and being fatigued during the day.

Allergies

F.P expressed intolerance of certain foods such as dairy. He is allergic to peanuts. He indicates to develop itch on the skin and throat when he consumes peanut products.

Current perception of Health

F.P explained that he has had good health in the last couple of years, but the current condition has provoked a lot of panic and discomfort.

Past Medical History

An examination of the past medical history of F.P indicates that he has not been diagnosed with major or chronic illness in the past. F.P indicates that he lost both of his maternal grandparents close to three years ago. This traumatic event drove him into a depression. He reached out for medical attention and was seen with a therapist for about three months. He states he is better now and is no longer depressed. The patient has not been hospitalized for any serious condition in the past. Also, the patient has not had any major surgery in the past.

Medications

F.P reported that he takes charco caps and Pepto-Bismol to reduce the gas and bloating. He is still taking the medication when his condition becomes severe. He also mentioned he use to take Sertraline after his grandparent’s past for depression, but he is no longer taking it because he does not feel depressed.

Family History

F.P reported that his father and brother have been treated with the same condition in the past. His mother also suffers from hypertension. His paternal grandfather had a history of colon cancer. Paternal grandmother is healthy. Maternal grandparents were healthy but passed away in a car accident.

Social history

F.P states he frequently eats out and not at home. He has been working as a mechanic now for 2 years. However, his previous job was as a server in a restaurant. F.P is currently married and lives at home with his wife and two children. He states he smokes tobacco but he’s just a social smoker. F.P states he does drink alcohol usually only on the weekends. His sexual orientation is heterosexual, and he uses condoms. He is currently sexually active with his wife at least two to three times a week.

Screening test

Various testing was required for F.P The screening test included CT scan, colonoscopy, and a flexible sigmoidoscopy. Additional tests included upper endoscopy and lactose intolerance test.

Immunization HX

F.P received all the immunization as a child with the most recent being Tetanus vaccination, which took place two months ago and also received an Influenza vaccine which took place a week ago.

Review of Systems

General: Denies weight loss. Denies loss of appetite. Denies fever. Denies weakness. Denies night sweats. Denies anorexia. Denies malaise.

HEENT: Denies headaches. Denies head injuries. Denies glasses. Denies change in vision. Denies flashing lights. Denies glaucoma. Denies cataracts. Denies changes in hearing. Denies ear pain. Denies discharge. Denies ringing. Denies dizziness. Denies nose bleeds. Denies nasal stuffiness. Denies post-nasal drip. Denies history of nasal polyps. Denies frequent colds. Denies swelling of lips and tongue. Denies bleeding gums. Denies hoarseness. Denies bleeding gums. Denies pyorrhea. Denies caries. Denies dentures. Denies extractions. Denies sore throat. Denies strep throat. Denies rheumatic fever.

Neck: Denies lumps. Denies swollen glands. Denies goiter. Denies stiffness. Denies pain.

Lymphatics: Denies swollen lymph nodes on neck. Denies swollen lymph nosed on axillae. Denies swollen lymph nodes on epitrochlear areas. Denies swollen lymph nodes in inguinal area

Breast: Denies lumps. Denies pain. Denies nipple discharge. Denies enlargement.

Lungs: Denies Shortness of breath. Denies chest tightness. Denies cough. Denies wheezing. Denies congestion. Denies bronchitis. Denies emphysema. Denies trouble breathing. Denies hemoptysis. Denies pleuritic chest pain. Denies blue discoloration on lips or nailbeds. Denies history of TB. Denies recurrent pneumonia. Denies history of environmental exposure.

Cardiovascular: Denies palpitations. Denies chest pain. Denies hypertension. Denies blue fingers/toes. Denies skipping heat beats. Denies Gx of murmur. Denies Hx of heart medication. Denies dyspnea. Denies PND. Denies orthopnea. Denies edema. Denies known heart disease. Denies history of rheumatic fever. Denies syncope or near syncope. Denies pain in posterior calves. Denies varicosities. Denies thrombophlebitis. Denies abnormal electrocardiogram.

GI: Denies blood in stool. Admits diarrhea. Denies vomiting. Denies vomiting blood. Denies constipation. Denies nausea. Admits abdominal pain. Admits changes in bowel habits. Admits excessive flatus. Denies rectal hemorrhoids. Denies passing black tarry stools. Denies pain when swallowing. Denies heart burn. Denies change in appetite. Admits sensation of filing up earlier than usual. Denies jaundice. Denies liver or bladder problems. Denies hepatitis.

Male/female genital: Denies changes. Denies lesions. Denies Hx of STD. Denies testicular pain. Denies testicular swelling. Denies scrotal mass. Denies infertility. Denies impotence. Denies changes in libido. Denies sexual difficulties. Denies hernias.

GU: Denies any discharge. Denies difficulty urinating. Denies pain or burning. Denies urgent need to urinate. Denies incontinence. Denies dribbling. Denies blood in urine. Denies UTI. Denies kidney stones. Denies prostate infection. Denies CVA. Denies suprapubic pain. Denies polyuria. Denies stones. Denies inguinal pain. Denies incontinence.

Neuro: Denies headache. Denies seizures. Denies loss of consciousness. Denies blackout. Denies fainting. Denies paralysis. Denies weakness. Denies loss of muscle size. Denies muscle spasm. Denies tremors. Denies involuntary movement. Denies numbness. Denies feeling pins or needles. Denies local weakness. Denies tingling. Denies memory changes. Denies vertigo or dizziness. Denies muscle atrophy.

Musculoskeletal: Denies joint stiffness. Denies leg cramps. Denies joint pain. Denies back pain. Denies neck pain. Denies muscle aches. Denies varicose veins. Denies clot in vein. Denies arthritis. Denies gout. Denies joint swelling or tenderness or effusion. Denies limitation of motions. Denies history of fractures.

Activity & Exercise: Admits 20 minutes of exercise daily.

Psychosocial: Denies depression. Denies high stress. Denies mood swings. Denies suicidal ideation. Denies obsessive- compulsive tendencies. Denies anxiety. Denies nightmares. Denies nervousness. Denies irritability. Denies insomnia. Denies hypersomnia, phobias, or tension.

Derm: Denies lesions. Denies moles. Denies rash. Denies itching. Denies dry and sensitive skin. Denies hives. Denies hair loss. Denies lumps. Denies jaundice. Denies changes in hair or nails.

Endocrine: Denies thyroid trouble. Denies heat or cold intolerance. Denies excessive sweating or flushing. Denies diabetes. Denies excessive thirst or hunger or urination.

Hematologic: Denies anemia. Denies easy bruising or bleeding. Denies pas transfusion and reactions.

Nutrition: Denies loss of appetite.

Sleep/Rest: Admits difficulty sleeping due to pain.

Physical Exam

Height: 160 cm. Weight: 82.6 kg. BMI: 32.3% BP: 130/86. (Right are sitting) HR 84. (Regular HR) RR 16. O2: 98% Temp: 98.3 degrees Fahrenheit (Taken Orally). Blood glucose, 135.

General: Alert, oriented x4. Weakness, fatigue, stomach pains.

HEENT: Head is normocephalic and hair is normal distributed. Symmetrical no signs of abnormalities. No lesion or tenderness presented. The eardrum is translucent, the auditory carnal looks normal, the external ear is tender and has no lesions. Patients hearing is normal ears are symmetrical and no signs of discharge or infection. Patients nose is midline and nasal patency present. Patients’ uvula is midline and gag reflex present the mucosa has no sign of swelling, infection, or bleeding. The tongue has no lesion, and the teeth are present and in the proper dentition no signs of sores or lesions.

Neck: Symmetrical no tenderness or masses palpable. Trachea is midline. Full ROM. No signs of swelling. No JVD distention and no bruits.

Pulmonary: Breath sounds clear to auscultation. Chest wall symmetrical bilaterally. No signs of lesions, scares from surgeries. Palpation normal. Tactile fremitus equal bilaterally.

Cardiovascular: Auscultation is normal, Normal S1 and S2. No murmurs presented. Capillary refill less than 3, pulses are equally 2+ bilateral with no bruits. No signs of edema. Visible PMI. No thrills presented.

Breast: (Male Patient) No masses or tenderness. No discharge.

GI: Abdominal pain in the lower abdomen, gas, and bloating. No scares or lesions on the abdomen. No sign of bruits. Hyperactive bowel sounds.

Male/female genital: Normal genitalia for age.

GU: No penal lesions or discharge. Normal distribution of hair. Normal scrotum. Patient is circumcised. No masses or tenderness on testes. No signs of epididymitis.

Neuro: Alert, oriented x4. Speech is clear, appropriate, and coherent. Sensation intact to touch.

Musculoskeletal (upper and lower): Normal gait. Full ROM in upper and lower extremities. Muscle strength is normal. No signs of swelling or edema. No signs of varicose vein present. Pulses full and equal. No CVA tenderness. Normal posture.

Derm: No lesions, scares. Normal skin temperature throughout body. No redness or swelling observed. Skin is normal with standard hair distribution and temperature. No pallor edema. No cyanosis.

Nutrition: Imbalanced nutrient level with deficiency of vitamins and low fiber intake in the body. Patient states he does not drink a lot of fluid.

Psychological: Appropriate mood and affect.

Activity & Exercise: at least 20 minutes of exercise daily

Labs

Significant data contributing

Upper endoscopy results indicate an overgrowth of bacteria. The patient also reported experiencing recurrent abdominal pain (RAP), a common symptom of irritable bowel syndrome (IBS). Genetic factors might also have contributed to the condition because of the reported family history. Flexible sigmoidoscopy indicated colonic motility disturbances. The results also indicated increased sensitivity to food, gas, and stool in the bowel. Abdominal pain also seems to ease after passing the bowel.

Differential Diagnoses

1. Crohn's disease

2. Helicobacter Pylori

Principal Diagnoses

1. Mild Irritable Bowel Syndrome (IBS).

Plan

Diagnosis: IBS

Diagnostic Testing: IBS/Colonoscopy

Pharmacological Treatment: Eluxadoline (Viberzi) of 100g (tablet) taken twice a day after meals. Rifaximin (Xifaxan) of 550mg (tablet) take three times daily for two weeks.

Education: Taking small balanced diets with plenty of fiber and vitamins. Increase of fluid intake. Taking part in swimming, yoga, light cycling, and walking or any exercise patient prefers. Other lifestyle changes include avoiding junk food and intake of heavy meals before bed. Only taking medications prescribed by the physician.

Referrals: If symptoms persist, the patient will be referred to a GI specialist.

Follow-up: 14 days after completion of medication, follow up will be done in clinic.

Anticipatory Guidance: Ensuring that the recommended feeding and medication guidelines are followed. Reporting any adverse effects to the physician immediately.

Signature (with appropriate credentials): MSN, APRN, FNP-Student

Cite current evidenced based guideline(s) used to guide care (Mandatory)

The practitioner must follow the recommended standard guidelines for treating IBS. The medication varies from one patient to another based on the level of severity (Basnayake, 2018). The doctor will first treat diarrhea with medication, dietary changes, and behavior change modifications. Eluxadoline and Rifaximin are recommended for treating diarrhea (Lembo, Pimentel, Rao, Schoenfeld, Cash, Weinstock… & Forbes, 2016). Antidepressants and antispasmodics can be used to treat pain in the abdomen. Behavior therapy helps to relieve anxiety and stress which more often complicate the condition (Oświęcimska, Szymlak, Roczniak, Girczys-Połedniok & Kwiecień, 2017). The therapy also includes choosing better dietary choices such as healthy fats found in nuts and salmon, whole grains, fruits, and vegetables (Defrees & Bailey, 2017). Cognitive Behavior Therapy (CBT) is effective in improving IBS symptoms by changing behavior patterns and thoughts. The therapy can be used to help the patient quit smoking completely to reduce the risk and optimize recovery. Alternative treatment remedies include massage, hypnotherapy, and meditation. Gut-focused hypnotherapy is one of the most effective strategies for improving IBS symptoms (Simon, Engström, Icenhour, Lowén, Ström, Tillisch… & Walter, 2019). A massage helps the patient to relax while hypnotherapy and meditation help the patient to relax tight stomach muscles.

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: M.J

Age: 55 years

Date: September 2, 2020

Dispense: Eluxadoline (Viberzi) 100g twice a day after meals.

No Substitution Refill: 0

Signature: MSN, APRN, FNP-Student

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: M.J

Age: 55 years

Date: September 2, 2020

Dispense: Rifaximin (Xifaxan) of 550mg three times a day for two weeks.

No Substitution Refill: 0

Signature: MSN, APRN, FNP-Student

References

Bischoff, S. C., Escher, J., Hébuterne, X., Kłęk, S., Krznaric, Z., Schneider, S. Forbes, A. (2020). ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease. Clinical Nutrition, 39(3), 632-653. doi:10.1016/j.clnu.2019.11.002

Klag, T., Stange, E. F., & Wehkamp, J. (2015). Management of Crohn's disease – are guidelines transferred to clinical practice? United European Gastroenterology Journal, 3(4), 371-380. doi:10.1177/2050640615580228

Matsuoka, K., Kobayashi, T., Ueno, F., Matsui, T., Hirai, F., Inoue, N., Shimosegawa, T. (2018). Evidence-based clinical practice guidelines for inflammatory bowel disease. Journal of Gastroenterology, 53(3), 305-353. doi:10.1007/s00535-018-1439-1

Ueno, F., Matsui, T., Matsumoto, T., Matsuoka, K., Watanabe, M., & Hibi, T. (2015). Evidence-based clinical practice guidelines for Crohn's disease, integrated with the formal consensus of experts in Japan. Journal of Gastroenterology, 48(1), 31-72. doi:10.1007/s00535-012-0673-1

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