Wk.7 Practicum: Soap Note

July 15th,2016

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SoapNote

SUBJECTIVEDATA

ChiefComplaint (CC): Patient presented to the clinic with RUQ

Abdominalpain.

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&amp 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.

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Medication:Patientcurrently taking prenatal vitamin.

PNV:Yes

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:&nbspG4 P2002.Denies any history of STI’s or virginal infections. She issexually active. No pain or bleeding with intercourse.&nbsp 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: &nbspHistoryof Tobacco use at age 15, quit at 25years of age. No history ofmarijuana use. Never drink&nbsp&nbsp alcohol.

FamilyMedical background:Mother died at age 76&nbspof&nbspcolon cancer and Alzheimer`sdisease. Father is 82 has Diabetes type2.

Immunization:Immunization Up to date

Reviewof Systems:

General:Wellbuilt.

HEENT:Deniesany headaches, No vision blurring.

Neck:N/Aper HPI

Respiratory:NoDOE .Denies coughs.

Cardiovascular/PeripheralVascular: Nochest pain or palpitations. Denies any &nbsp 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.&nbsp

Genitourinary:No pain with urination. No blood noted in her urine.&nbsp&nbspFrequenturination due to pregnancy.

Gynecological:&nbspDenies pain or bleeding with intercourse. No vaginald/c itch, swelling: No vaginal itching or swelling

Musculoskeletal:Nocomplains of pain.

Psychiatric:Reportsno concerns.

Neurological:Alert and oriented x 3

Skin:&nbsp&nbspNorashes or lesions.

Hematologic:N/A

Endocrine:Deniesany heat /cold intolerance

Allergic/Immunologic:NKDA

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OBJECTIVEDATA

PhysicalExam

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 &nbsp

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.&nbsp

Lungs:soundsclear to auscultation bilaterally. No wheezing.

NECK:&nbspThyroidhas 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.

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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.

Uterus-Tender.

Approx.GA from exam- 3 months

Musculoskeletal:Patient does not present any difficulty in movement. No jointswelling or deformities.

Neurological:Grosslyintact.

Skin:Intact.No rashes.

ASSESSMENT:

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&nbspappearto 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.

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PLAN

TreatmentPlan:Patient’s Workup will include a sonogram of the RUQ itis 95% accurate in detecting gallstones in the gallbladder,BMP, CBC, urinalysis, C&ampS, 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. &nbspRegular check-up should be conducted to improve thetreatment method and manage the patient’s recovery (Makalu’s,2012).&nbsp

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.

DiseasePrevention:

Patientdoes have a family history of colon cancer.&nbsp 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&nbsp 0.4mg of folic acid perday for the purpose of reducing the risk of having the pregnancyaffected with spina bifida or other NTDs &nbspIt would berecommended that she takes&nbsp pre-natal vitamins and&nbsp &nbsp1,000milligrams (mg) calcium&nbsp a day before, during, and afterpregnancy.&nbsp

Patientwas given Rx for PNV as a confirmation of the pregnancy. &nbsp

REFLECTIONNOTE

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.

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