SOAPNote Template for Small Bowel Obstruction Patient

Read SOAPNote Template for Small Bowel Obstruction Patient at Desklib. Get a complete overview of the patient's complaints, diagnosis, and differential diagnosis. Find out the recommended immunizations and medication(s) for the patient.

SOAPNote Template
Jacksonville State University
SOAP
SUBJECTIVE
Statement based on patients response of events over the course of hosp
Subjective Statement:
History of Present Illness (OLD CARTS):
This patient is a 52-year-old African American female with past medical history significant
for history of depression, anxiety, hypertension, obesity status post gastric bypass surgery
comes here to the hospital within a few days of discharge with the complaints of
abdominal pain and nausea and vomiting. Patient had gastric bypass surgery in July and
since then has had problems with nausea and vomiting. She was admitted recently by
her surgeon and had underwent surgical intervention for incarcerated hernia. Patient was
discharged few weeks ago and apparently did well after discharge. About 3 weeks ago
she started having nausea and vomiting and the symptoms would be on and off. Her the
last few days her symptoms got really worse and she decided come to the ED. Denies
any fever or chills or night sweats. Denies any hematemesis melena constipation or
diarrhea. She was evaluated in the ED and was seen by her surgeon and had a CT scan
done
Medication History/Current Medication:
The patient is currently active on the following medications, prior to visit:
 Sodium Chloride 0.9, 1000 ml IV (125 ml/hour)
 Famotidine 20 mg/ 2 ml IV (Scheduled to be administered for every 12 hours)
 Ondansetron 4 mg/2 ml IV (Scheduled to be administered for every 6 hours as
needed)
 Hydralazine HCL 10 mg/ 0.5 ml IV (Scheduled to be administered after every 4
hours as needed)
 Acetaminophen 650 mg Oral (Scheduled to be administered for every 4 hours as
needed)
 Morphine Sulphate 1 mg/0.5ml + 2 mg/1 ml IV (Scheduled to be administered for
every 4 hours as needed)
Home medications to be prescribed in the future:
 Metoprolol Tartarate (Lopressor) 50 mg orally, to be taken daily
 Amitiza Capsule 24 mg orally, 2 times daily
 Cyclobenzaprine, 10 mg orally, 3 times daily
 Gabapentin, 400 mg orally, 3 times daily
Allergies:
 No complaints or history of any drug allergies
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Previous Medical History:
 Depression
 Obesity
 Hypertension
 Anxiety
 Osteoarthritis
 GERD
Previous Surgical History:
 Gastric bypass surgery
 Spinal fusion
 Cholecystectomy
 Repair of incarcerated hernia
 Bilateral tubal ligation
 Rotator cuff repair
 Hysterectomy
 Lysis of adhesions
Social history:
 No reported complaints or usage and consumption of alcohol and illicit drugs
Family history:
 Absence of contributors to present health complaints after reviewing
OBJECTIVE
Describeanypositiveandnegativefindingsrelevanttothispatient'sproblem.Becarefultoincl
udeONLYthosepartsoftheexamthatyouperformedduringthisencounter.Includeresultsof
anytestsdoneduringthisencounter.
Physical Exam:
12 Review of Systems conducted as per History of Present Illness (HPI), which was
found to the negative for the presence of any chills or fever. Denial of any feeling of
bowel movements or perceptions of doom by patient.
General: Patient is resting comfortably with no signs of acute distress
Eyes: PERRLA, absence of conjunctival pallor and schleral icterus
ENT: OMM, absence of pharyngeal erythema
Neck: Supple, absence of adenopathy or jugular vein distension
Lungs: CTA, absence of abnormalities in air entry
Cardiovascular: regular rate and rhythm, absence of any murmurs, jugular vein
distension and pedal edema
Abdominal: distended, decreased bowel sounds observed in all quadrants, follow up
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prior to visit: incisions were observed to be normal, minimal tenderness with absence
of guarding or diffuse rebound
Genitourinary: absence of hernia, foley catheter in place
Musculoskeletal: Absence new arthopathy
Skin: Absence of any rashes
Neurology: Patient is alert and oriented in speech, hearing and vision
Peripheral vascular: Absence of cyanosis, absence clubbing, peripheral pulse
normal +++
Vital Signs: Temperature: 98.3 F, BP: 107/67, Pulse: 109, RR: 20, O2 Saturation:
99.0%, BMI: 43.9
Diagnostics:
Radiology: CT films were reviewed, revealed suspected obstruction in the bowel due
to port side hernia
Labs: Urine color: Amber, straw, yellow, Urine clarity: clear, Glucose: 132 H, BUN:
17, Creatinine: 0.75, Sodium: 140, Potassium: 5.1, Chloride: 105, Calcium: 9.5, Total
protein: 7.8, Albumin: 4.3, Globulin: 3.5, Bilirubin: 0.9, SGPT: 91 H, SGOT: 93 H,
Alkaline phosphatase: 154 H,
ASSESSMENT
Based on what you have learned from the SOAP, Provide an overview/impression of
the patient complaints that leads to the diagnosis and differential diagnosis. List 3
diagnoses that might explain this patient’s complaint
Primary Diagnosis + Differential Diagnosis: Small Bowel Obstruction
Second Diagnosis + Differential Diagnosis: Port side hernia
Third Diagnosis + Differential Diagnosis : Hyperglycemia
Add additional diagnosis and differentials as needed: dehydration/inability to remain
adequately hydrated, BMI within range of class III obesity
PLAN
Provide evidence- based statement with citation (do not use Epocrates) for all
elements of the plan. Do not use only one EB statement at the end of the document.
Diagnostic Studies:
Perform a cardiovascular assessment considering high SGPT, SGOT, Alkaline
Phosphatase values
 Daily monitoring and documentation of blood pressure and heart rate
 Perform a total lipid blood profile comprising of total cholesterol, HDL, LDL,
triglyceride values
 Perform an ECG to monitor abnormalities in heart rhythm and valve function
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Conduct routine Abdominal Assessment
 Auscultation to observe for bowel sounds to assess presence of distension
 Palpation and percussion to observe for protrusions or blockages
 Compare with previous abdominal assessment findings
Conduct liver assessment:
 Obtain values of liver enzymes (SGPT, SGOT, Alkaline phosphatase)
 Compare with previous liver enzyme profile values to assess for hepatic, renal,
cardiac or organ damage
Nutritional assessment:
 Obtain values of serum vitamin D, b12, b9 values to screen for deficiencies after
gastric bypass
 Administer fluids intravenous to improve patient’s hydration status
CT screening for bowel obstruction:
 Colonoscopy
 Surgical repair of hernia and abdominal fistula
 Assess need for surgical resection and colonoscopy
Glucose monitoring:
 Obtain routine blood glucose (fasting, post prandial) and glycosylated haemoglobin
 Compare with previous values to assess for diabetic symptoms
Psychological assessment:
 Mental State Examination
 Hamilton Depression Rating Scale
 Patient Stress Questionnaire
 Generalized Anxiety Disorder-7
 Review for relapse of anxiety and depression symptoms
Bibliography:
Coblijn, U. K., de Raaff, C. A., van Wagensveld, B. A., van Tets, W. F., & de Castro, S. M.
(2016). Trocar port hernias after bariatric surgery. Obesity surgery, 26(3), 546-551.
Lambertz, A., Stüben, B. O., Bock, B., Eickhoff, R., Kroh, A., Klink, C. D., ... & Krones, C.
J. (2017). Port-site incisional hernia–a case series of 54 patients. Annals of
Medicine and Surgery, 14, 8-11.
Wijerathne, S., Agarwal, N., Ramzi, A., Liem, D. H., Tan, W. B., & Lomanto, D. (2016).
Single-port versus conventional laparoscopic total extra-peritoneal inguinal hernia
repair: a prospective, randomized, controlled clinical trial. Surgical
endoscopy, 30(4), 1356-1363.
Recommended Immunizations/Medication(s):
 Sodium Chloride 0.9, 1000 ml IV (125 ml/hour)
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 Famotidine 20 mg/ 2 ml IV (Scheduled to be administered for every 12 hours)
 Ondansetron 4 mg/2 ml IV (Scheduled to be administered for every 6 hours as
needed)
 Hydralazine HCL 10 mg/ 0.5 ml IV (Scheduled to be administered after every 4
hours as needed)
 Acetaminophen 650 mg Oral (Scheduled to be administered for every 4 hours as
needed)
 Morphine Sulphate 1 mg/0.5ml + 2 mg/1 ml IV (Scheduled to be administered for
every 4 hours as needed)
 Metoprolol Tartarate (Lopressor) 50 mg orally, to be taken daily
 Amitiza Capsule 24 mg orally, 2 times daily
 Cyclobenzaprine, 10 mg orally, 3 times daily
 Gabapentin, 400 mg orally, 3 times daily
 Oral feedings to be administered post surgical operation
 Intravenous administration of small amount of Lactated Ringer’s solution bolus
 After patient oral feeding resumes, administration of oral diet comprising of low to
moderate fiber, low sugar, low fat and moderate protein diet comprising of soft or
texturally modified foods.
Bibliography:
Ahlqvist, S., Björk, D., Weisby, L., Israelsson, L. A., & Cengiz, Y. (2017). Trocar Site
Hernia After Gastric Bypass. Surgical technology international, 30, 170-174.
Buckley, F. P., Vassaur, H. E., Jupiter, D. C., Crosby, J. H., Wheeless, C. J., & Vassaur,
J. L. (2016). Influencing factors for port-site hernias after single-incision
laparoscopy. Hernia, 20(5), 729-733.
Karampinis, I., Lion, E., Grilli, M., Hetjens, S., Weiss, C., Vassilev, G., ... & Otto, M.
(2019). Trocar Site Hernias in Bariatric Surgery—an Underestimated Issue: a
Qualitative Systematic Review and Meta-Analysis. Obesity surgery, 29(3), 1049-
1057.
Rogers, A., Rossi, A., & McLaughlin, D. (2015). An expanded retrospective review of
trocar-site hernias in patients undergoing laparoscopic gastric bypass. Surgery for
Obesity and Related Diseases, 11(6), S87-S88.
Patient Instructions:
 Engage in monthly anthropometric assessment (height, weight, BMI, waist
circumference measurements)
 Daily home monitoring of blood glucose
 Monitoring of glycosylated haemoglobin after every 3 months
 Daily engagement in a mild aerobic exercise as per specialist supervision
 Consumption of a of low to moderate fiber, low sugar, low fat and moderate protein
diet as per USDA guidelines and specialist supervision
 Monthly or quarterly appointments with general practitioner along with monitoring of
blood pressure
 Monthly abdominal and cardiovascular assessments
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 Lipid profile, liver enzyme, serum creatinine, serum electrolytes, serum protein,
serum vitamin blood tests every 3 to 6 months or as per specialist instruction
 Yearly mental health assessment
 Report immediately for the presence of any discomfort or relapse of symptoms
Bibliography:
Ece, I., Yilmaz, H., Alptekin, H., Yormaz, S., Colak, B., & Sahin, M. (2018). Port site
hernia after laparoscopic sleeve gastrectomy: a retrospective cohort study of 352
patients. Updates in surgery, 70(1), 91-95.
Haliburton, B., Chiang, M., Marcon, M., Moraes, T. J., Chiu, P. P., & Mouzaki, M. (2016).
Nutritional intake, energy expenditure, and growth of infants following congenital
diaphragmatic hernia repair. Journal of pediatric gastroenterology and
nutrition, 62(3), 474-478.
Hoeft, M. A., & Ortiz, V. E. (2016). Gastrointestinal and Hepatic Changes with Obesity.
In Perioperative Anesthetic Care of the Obese Patient (pp. 44-50). CRC Press.
Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety
disorders with the GAD-7 and GAD-2: a systematic review and diagnostic
metaanalysis. General hospital psychiatry, 39, 24-31.
Rossi, A., McLaughlin, D., Witte, S., LynSue, J., Haluck, R. S., & Rogers, A. M. (2017). An
expanded retrospective review of trocar site hernias in laparoscopic gastric bypass
patients. Journal of Laparoendoscopic & Advanced Surgical Techniques, 27(6),
633-635.
Slim, K., & Standaert, D. (2019). Enhanced recovery after surgical repair of incisional
hernias. Hernia, 1-6.
Thompson, B. J., & Uhley, V. (2018). Obesity, It’s More Than Appearance: An Innovative
Use of Anatomical Dissections to Teach About Obesity and Nutrition. The FASEB
Journal, 32(1_supplement), 635-32.
Timmerby, N., Andersen, J. H., Søndergaard, S., Østergaard, S. D., & Bech, P. (2017). A
systematic review of the clinimetric properties of the 6-item version of the Hamilton
Depression Rating Scale (HAM-D6). Psychotherapy and psychosomatics, 86(3),
141-149.
Follow-up or Referral:
 Follow up with cardiologist for abnormal cardiac findings and lipid profile
 Follow up with nutritionist for difficulties in food intake, prevalence of deficiencies
and diabetic symptoms
 Follow up with gastroenterologist after surgical hernia repair
 Follow up with general practitioner
 Follow up with psychologist in case of abnormalities in mental health
 Follow up with diabetologist in case of prevalence of diabetic symptoms
 Follow with general practitioner and any specialist (nutritionist, gastroenterologist) if
symptoms re-appear within 1 year.
 Follow up with fitness practitioner for exercise interventions and weight
management
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