Analyzing the SOAP note
There are several cases when a patient has been misdiagnosed and treated for an illness that they are not suffering from. Some cases it is because of recklessness and carelessness of the nurses or the medical officer in charge, while at other times, the misdiagnosis is as a result of unavoidable cases. To avoid the cases of misdiagnosis, there are several things that are recommended to be taken care of.
JR, 47 years old Woman came in with the chief complain of generalized abdominal pain and diarrhea .The onset of symptoms started 3 days ago. He states “not been able to eat, with some nausea afterwards “as well. The subjective data and objective data given in the scenario is very significant for the health care provider to rule out the correct diagnosis. Subjective and objective data give an understanding of the patient condition. It’s a role of the provider to collect all the pertinent information related to patient chief complain so that the pieces can be put together. The history of the patient, such as understanding the history of their family, would help in giving the diagnosis that is accurate.
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There are several reasons that cause abdominal pain and the initial goal of assessment is to differentiate the severe life threatening condition from the primary role of provider is to assess the acute life threatening situation from acute mild to chronic recurrent condition. This case scenario is provided with good subjective and objective data but due to nature of the symptom presentation, health provider might need more information for further work up.
There are three generalize factors responsible for most of the abdominal pain (Dains, Baumann, & Sheibel 2016):
Muscle contraction and distension due to tension in the Gastrointestinal wall
Ischemia
Inflammation
Following assessment are done on JR’s to analyze the possible cause of abdominal pain..RF onset of pain is acute in nature which started three days back and the progression of pain when started was 9/10 but on the day of the doctor visit it is 5/10 followed by some nausea afterwards. On assessment JR’s abdomen is soft and tender with hyperactive bowel sound, and location of the pain is LLQ. However, as per ( Access medicine, 2019) subjective assessment must include exposure to possible food toxin (food poisoning, any radiation or chemotherapy exposure).Not only this, provider should always ask the patient regarding bowel habits.
The assessment component of the SOAP note requires that a summary of the information from the patient be made. The physician should give a summary of the information from the patient should be summarized in a way that captures all the information and that allows physicians to understand what the patient is going through (Kettenbach, 2017). The physical exam should be given to the patient when there is a doubt that the symptoms are not reliable to give the proper diagnosis. The patient should be made to understand the need for such an exam if they are not willing to take the test (Dains et al., 2018). They should be made to understand that the exam will help to give the proper and accurate diagnosis and that this would help to give the proper prescription top the patient. The patient should also be made to understand the effect that is associated with getting the wrong prescription.
Plan
The plan component provides a treatment plan for the patient. It illustrates what the patient is suffering from and the type of treatment that they should be given. If all the steps that are described in the SOAP note are followed, it would be difficult to give a wrong diagnosis for the patient. Also, it would be possible for the patient to get the best treatment.
In this case, there are several differential diagnoses that may be associated with abdominal pain. Salmonella infection (Salmonellosis), Escherichia coli (E coli) infections, Bacterial Gastroenteritis, Giardiasis, and appendicitis are some of the five differential diagnostics (Dye, 2015). Nontyphoidal enterocolitis, eccentric fever as well as nontyphoidal focal diseases, are the three distinct salmonella infections typically produced. Bacterial Gastroenteritis, on the other hand, has symptoms that are vomiting, abdomen, diarrhea, and they can range from mild to severe. Cholecystitis and cholangitis are some of the common bacterial infection Escherichia coli. Giardiasis is an infection found throughout the world, and it’s a primary diarrheal disease. Finally, appendicitis is an infection that duels on the appendix as an inflammation.
The following are some of the diagnostic tests that get conducted when you Consider JR’s history of GI bleed in the past, provider should also ask regarding presence of vomiting. Coffee ground possible indicates GI’s bleed. In order to narrow the differential diagnosis, laboratory testing, imaging and patient physical examination should be based on the clinical presentation ( Access medicine, 2019 ).
The laboratory tests may not get indicated in most cases when there are clinical features of Viral Gastroenteritis. Patients with high fevers or those that appear systemically ill often give up their blood cultures (Ball et al., 2015). When there are no severe illnesses in some patients, the stool culture may not get conducted. These are because most of the most acute diarrhea cases are of viral entology or self-limited. Physicians may, at times need to identify potential pathogen; hence, they will obtain the stool cultures from patients with acute diarrhea.
References
Access medicine, (2019) Abdominal Pain: Constructing a Differential Diagnosis. https://accessmedicine.mhmedical.com/content.aspx?sectionid=61696569&bookid=1088
Ball et al., (2015) Vital signs and pain assessment
Dains, J. E., Baumann, L. C., Scheibel, P., & Dains, J. E. (2018). Advanced Health Assessment and Clinical Diagnosis in Primary Care.
Dye, D. (2015). Enhancing critical reflection of students during a clinical internship using the self-SOAP note. Internet Journal of Allied Health Sciences and Practice , 3 (4), 4.
Kettenbach, G. (2017). Writing SOAP notes . FA Davis Company.
