SOAP Note Analysis

SOAP Note Analysis

SOAP Note to be analyzed:

Episodic/Focused SOAP Note Exemplar

ABDOMINAL ASSESSMENT:

Subjective:

CC: My stomach hurts, I have diarrhea and nothing seems to help.
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10; WT 248lbs Heart: RRR, no murmurs

Lungs: CTA, chest wall symmetrical

Skin: Intact without lesions, no urticaria

Abd: soft, hyperactive bowel sounds, pos pain in the LLQ

Diagnostics:?

Assessment Diagnoses:
Left lower quadrant pain
Gastroenteritis

Assignment Instructions:
-Analyze the subjective portion of the note. List additional information that should be included in the documentation.
-Analyze the objective portion of the note. List additional information that should be included in the documentation.
-Is the assessment supported by the subjective and objective information? Why or why not?
-What diagnostic tests would be appropriate for this case, and how would the results be used to make a diagnosis?
-Would you reject/accept the current diagnosis? Why or why not?
-Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least three different references.

Solution

SOAP Note Assessment

Healthcare professionals utilize Subjective, Objective, Assessment, and Plan (SOAP) notes to summarize information related to a patient’s symptoms, diagnosis, and treatment plan. Although a standard format for documenting SOAP notes is still lacking, there are crucial details to be included in each section based on the patient’s problems (Sudarsan et al., 2021). The purpose of this assignment is to analyze a SOAP note for patient JR to establish important information that should have been added to make it complete.

Subjective Portion of the Note

The subjective portion of the note contains limited information that is inadequate to make a diagnosis. Detailed information should be provided in this section to enable the healthcare professional to make an accurate diagnosis (Sudarsan et al., 2021). In addition to what has been documented in the subjective portion of the note, it is important to add information regarding a review of systems including head, eyes, ears, nose, and throat (HEENT) assessment data and other systems such as cardiovascular, respiratory, abdominal, genitourinary, musculoskeletal, endocrine, psychiatric, neurological, and lymphatic/hematologic systems.

It is important to collect subjective information regarding how a patient is feeling in various systems to be able to relate the presented symptoms with possible organ dysfunction (Dains et al., 2016).

Although the SOAP note includes data about the chief complaint (CC), the information documented under the history of present illness (HPI) is not detailed enough to enable the healthcare provider to relate his symptoms with a specific health condition. For example, the patient has stated that his stomach hurts with diarrhea and nothing has helped so far. The healthcare provider should ask the patient to describe the nature of the pain, whether it is dull, sharp, excruciating, or radiating.

The patient should also describe the onset of the pain including relieving and exacerbating factors (Penner et al., 2020). Including all this information in the subjective portion of the note will make the data comprehensive enough to enable the healthcare professional to make an accurate diagnosis.

Objective Portion of the Note

            Information provided under the objective portion of the note is insufficient to enable the healthcare provider to make an accurate diagnosis. The provider should include additional details in this section. According to Sudarsan et al. (2021), the Objective section of a SOAP note should contain physical exam results of various body systems and results of diagnostic tests performed. To make the objective portion complete, the healthcare provider should add details regarding the physical assessment of the HEENT, genitourinary, musculoskeletal, endocrine, psychiatric, neurological, and lymphatic/hematologic systems assessment.

According to Penner et al. (2020), some health problems that present as abdominal pain may also affect other body organs such as the HEENT, genitourinary, rectum, neurological, or endocrine organs. This explains why it is important to include the physical assessment results of these body organs in the objective portion of the SOAP note. Additional information to be included in this section should be the diagnostic tests performed and the results obtained.

Alignment Between the Assessment and the Objective as well as Subjective Information

The assessment diagnoses given as left-lower quadrant pain and gastroenteritis are not aligned with the objective and subjective information. Diarrhea, abdominal pain, and nausea are the only subjective information that supports gastroenteritis as a diagnostic assessment. Vomiting, fever, abdominal cramping or pain, nausea, an increase in bowel movements, and watery diarrhea are the common symptoms of gastroenteritis in adults (Jassas et al., 2018). However, the patient has not complained of some of them.

Besides, abdominal pain due to gastroenteritis is usually concentrated in the central lower quadrant of the abdomen but not in the left lower quadrant (Jassas et al., 2018). Again, it is difficult to tell whether the patient has gastroenteritis or not because the healthcare provider has not conducted any diagnostic tests as evidenced by the lack of diagnostic results under the objective portion of the SOAP note (Bickley, 2018).

Appropriate Diagnostic Tests

The healthcare provider should order a number of diagnostic tests to make an accurate diagnosis. For instance, the provider should order a stool culture to examine whether the patient’s symptoms are due to bacterial or viral infections (Penner et al., 2020). Again, a complete blood count will help to detect the types of cells in the patient’s blood including eosinophils that are usually produced during parasitic infections (Dains et al., 2016).

Other tests that can be considered include a creatinine test to determine kidney function, colonoscopy to detect issues in the colon and rectum, and a rapid stool test to detect the organism that is causing the symptoms (Bickley, 2018). These tests will yield results that can guide the healthcare provider into making an accurate diagnosis.

Current Diagnosis and Differential Diagnoses

I would reject the current diagnosis. The reason is that the diagnosis of gastroenteritis with pain in the left lower quadrant of the abdomen is not adequately supported by subjective and objective information. Dains et al. (2016) recommend that a clinical diagnosis should be supported by both the subjective information obtained during history taking and objective information collected during physical examination. The three possible conditions that might be considered as the patient’s diagnosis are as follows;

• Ulcerative Colitis: Symptoms include abdominal pain, diarrhea, fatigue, fever, and increased bowel movement (Gajendran et al., 2019)
• Food Poisoning: Food poisoning usually causes abdominal pain, diarrhea, vomiting, and nausea (Kumar et al., 2020).
• Diverticulosis: This condition usually causes similar symptoms including pain in the left quadrant of the abdomen, fever, diarrhea, fever, blood in stool, nausea, constipation, and vomiting (Rangan & Lamont, 2020).

References

Bickley, L. (2018). Bates guide to physical examination and history taking (12th ed.). Philadelphia, PA: Wolters Kluwer.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.

Gajendran, M., Loganathan, P., Jimenez, G., Catinella, A. P., Ng, N., Umapathy, C., … & Hashash, J. G. (2019). A comprehensive review and update on ulcerative colitis. Disease-a-month, 65(12), 100851. https://doi.org/10.1016/j.disamonth.2019.02.004

Jassas, B., Khayat, M., Alzahrani, H. & Asali, A. (2018). Gastroenteritis in adults. International Journal of Community Medicine and Public Health, 5(11), doi:10.18203/2394-6040.ijcmph20184250

Kumar, A. (2020). Food Poisoning: causes, precautions, diagnosis and treatment: A brief review. World Journal of Biology and Biotechnology, 5(1), 33-36. https://www.researchgate.net/publication/348557320_Food_Poisoning_causes_precautions_diagnosis_and_treatment_A_brief_review

Penner, R., Fishman, M. B., & Majumdar, S. (2020). Evaluation of the adult with abdominal pain. UpToDate, Waltham, MA. Accessed, 6. https://www.uptodate.com/contents/evaluation-of-the-adult-with-abdominal-pain

Rangan, V., & Lamont, J. T. (2020). Small bowel diverticulosis: pathogenesis, clinical management, and new concepts. Current gastroenterology reports, 22(1), 1-7. https://doi.org/10.1007/s11894-019-0741-2

Sudarsan, P., Gowda, M. B. A., Anusha, R. J., Balu, D., Sadagoban, G. K., & Borra, S. S. (2021). Development and validation of A-SOAP note: Assessment of efficiency in documenting patient therapeutic records. Journal of Applied Pharmaceutical Science, 11(10):001–006.