Wk.7 Practicum: Soap Note
ChiefComplaint (CC): Patient presented to the clinic with RUQ
Historyof Present Illness (HPI):Patient is 34-year-old female G4P2.Patient complains of RUQ abdominalpain as well as indigestion without nausea and vomiting. Patientcomplains of experiencing abdominal pains for the last three weeks.Patient is 2 months pregnant. The continuous pain is positioned inthe upper right quadrant of her stomach. It started 3 weeks ago andis irregularly experienced in her right shoulder blade. Acute pain isusually accompanied by nausea (Lammert& Stokes, 2012). Eatingdeteriorates the pain, making her feel additional gas and bloating.Rolaids frequently diminishes the pain, but this did not improve inthe previous incident. On a Scale of 10, she rated the discomfort as8/10.
Medication:Patientcurrently taking prenatal vitamin.
Allergies:No known Allergies
PastMedical History (PMH): nosignificant PMH
Thepatient is approachable, well groomed, and well built. She does notshow any signs of distress.
PastSurgical History (PSH):Patient has no surgical record
Sexual/ReproductiveHistory: G4 P2002.Denies any history of STI’s or virginal infections. She issexually active. No pain or bleeding with intercourse.  Nohistory of abnormal pap smears. Last annual physical in March, of2016 with normal pap/HPV.
LMP:4 months ago
EDD:deliveryestimated in the next 3months
Personal/SocialHistory:  Historyof Tobacco use at age 15, quit at 25years of age. No history ofmarijuana use. Never drink   alcohol.
FamilyMedical background:Mother died at age 76 of colon cancer and Alzheimer`sdisease. Father is 82 has Diabetes type2.
Immunization:Immunization Up to date
HEENT:Deniesany headaches, No vision blurring.
Respiratory:NoDOE .Denies coughs.
Cardiovascular/PeripheralVascular: Nochest pain or palpitations. Denies any   recent change inswelling.
Gastrointestinal:increaseappetite. No diarrhea or constipation. No nausea/vomiting c/o RUQabdominal pain. No surrounding redness.12 weeks pregnant.
Breast:Symmetrical, areola equal and dark. There is tenderness.
Genitourinary:No pain with urination. No blood noted in her urine.  Frequenturination due to pregnancy.
Gynecological: Denies pain or bleeding with intercourse. No vaginald/c itch, swelling: No vaginal itching or swelling
Musculoskeletal:Nocomplains of pain.
Neurological:Alert and oriented x 3
Skin:  Norashes or lesions.
Endocrine:Deniesany heat /cold intolerance
Vitalsigns: theBP-116/74,T- 98.2 tympanic. P-78,R-18, the HT- 66” Weight- 159 lbs., BMI(Basal Metabolic Index) – 26, SPO2- 98%on RA.
LMP/EDD:patient estimated to deliver in the next 3 months
General:Well built.Attentive and oriented, in no distress, well-nourished, sufficientlyhydrated, marginally overweight because of the pregnancy and wellpresented.
HEENT:clearnoseand throat, no drainage or redness. Nose and throat are clear, noredness or drainage. Tympanic membranes intact no redness. Eyes areequal round and reactive to light.
Lungs:soundsclear to auscultation bilaterally. No wheezing.
NECK: Thyroidhas a normal size. Neck supple, no nodes, no thyromegaly, No JVD, nobruits.
Heart:Normalrate and rhythm. Heart sounds S1, S2 normal no S3, noS4, no murmurs.
PeripheralVascular: +2bilateral dorsal pulses.
Abdominal–no presence of surgical scars and no dissension. Abdominal examreveals positive bowel sounds, soft, no distension, non-tender topalpation all quadrants, no masses, no organomegaly, no guarding andno rebound. Healthy active bowel sounds in all the four quadrants(Nyirjesy, 2013).
Uneasinesswas felt in light and deep shudder of the upper right quadrant. Thepatient ‘sliver and spleen are not distended. The patient had norebound sensitivity or guarding. Full array of motion felt in herbody parts including shoulders, elbows, hands, hips, knees as well asankles without pain tenderness or inflammation recorded.
Fundalheight measured: 5.6
Transvaginalultrasound: undertakeninstead of a pelvic exam to check for any infection in the pelvis, anabnormal pelvic.
Exteriorgenitalia -standard hair distribution, and no abrasions
Vagina- pinkmucosa with no abrasions or abnormal discharge.
Cervix:examined for any changes and noted as ok.
Approx.GA from exam- 3 months
Musculoskeletal:Patient does not present any difficulty in movement. No jointswelling or deformities.
Primarydiagnosis: gall stones
DifferentialDiagnosis:Gallstone disease, hepatitis, and peptic ulcer disease (Laurell,2015).
Gallstone disease: Gallstonedisease is the most common disorder affecting the biliary system.There are several different treatment options for gallstone disease,including medication, surgery and shock wave therapy. The course oftreatment depends on the symptoms and the type of gallstones. StudiesshowGallstones appearto be more common during pregnancy. About 80% of people withgallstones do not have any symptoms for many years Patient is likelyto be diagnosed with the disease because of the pain from her upperright quadrant. Being female, being pregnant, and being overweightare risk factors that contribute to the diagnosis of the Gall stonedisease.
PepticUlcer Diagnosis: Thepatient complains of pain in the upper right quadrant that rules outthe possibility of Peptic Ulcer Diagnosis. Burningpain is the most common symptom.
Primarydiagnosis wouldbe gallstone disease as suggested by the abdominal pain and deeppalpitation in the upper right quadrant.
TreatmentPlan:Patient’s Workup will include a sonogram of the RUQ itis 95% accurate in detecting gallstones in the gallbladder,BMP, CBC, urinalysis, C&S, urine micro includingHgA1C. Thesuggested pharmacological treatments include usingnon-steroidalanti-inflammatory drugs, while the non-pharmacologicalencompass lipid modification, calorie restriction, or physicalactivity interventions. Since the patient is pregnant, the mostappropriate treatment option would be then on-pharmacologicalmeasures. An extensive management plan should include the length oftime for the treatment and a regular check-up. The rationale for thetreatment regards the fact that using drugs may interfere with thepregnancy.  Regular check-up should be conducted to improve thetreatment method and manage the patient’s recovery (Makalu’s,2012).
Surgicaloptions will be considered in the event that the symptoms do notresolve. Majority of the Ob patients have cholecystectomy duringpregnancy prompting the need to consider surgical interventions as atreatment option.
HealthPromotion: Asa nurse practitioner, in a similar patient evaluation, I assesswhether the patient’s pregnancy is at risk or not.
Researchsuggests that abdominal pain during pregnancy may be difficult todiagnose. Besides, with the intention of ensuring that the pregnancyis protected, proper diagnosis and recommendation of thenon-pharmacological interventions would be appropriate. Earlycolonoscopy is required because mother died of colon cancer andmonitoring HgA1C will be required because of family history of DMtype 2.
Patientdoes have a family history of colon cancer.  Referral forcolonoscopy after delivery is needed due to family history of coloncancer. Monitoring HgA1C is equally needed due to family history oftype 2 Diabetes. She need folic acid  0.4mg of folic acid perday for the purpose of reducing the risk of having the pregnancyaffected with spina bifida or other NTDs  It would berecommended that she takes  pre-natal vitamins and   1,000milligrams (mg) calcium  a day before, during, and afterpregnancy.
Patientwas given Rx for PNV as a confirmation of the pregnancy.
Thediagnosis of abdominal pain and cause in a pregnant patient is alwaysvery challenging given that there is an unborn child involved. Onemight think it is gallstone disease, hepatitis, or peptic ulcerdisease, while it is a problem of the pregnancy. Therefore, what Iwould differentlyin a similar patient evaluation is to check for the status of thepregnancy and rule out any problems related to that. After that Iwould undertake a thorough diagnosis. Given that the patient ispregnant, part of the observations will include the patient’sweight, height, GA, PNV, as well as EDD. These fundamentals will helpdecide on the best treatment option with little or no effect on thepregnancy.