ComprehensiveSOAP Note Template
FlorenceEze.
WaldenUniversity
March19, 2016
Patentinitials: J.M Age: 30 Gender: Male
SUBJECTIVEDATA
ChiefComplaint (CC): Thepatient is a thirty years, old male white who came for a medicalcheck-up after experiencing abdominal pain and blood in the stool.The condition has been in place for month. The patient also sufferedrecently from severe rectal bleeding.
Historyof the Present Illness (HPI):For several years, the patient had been receiving treatment forCrohn’s disease. He has been hospitalized two times for the samecondition.
Medications:
Allergies:Urticaria
PastMedical History (PMH):Delayed growth and development during his early age
PastSurgical History (PSH):No surgical history
Sexual/ReproductiveHistory:Normal
Personal/Social History:Married for four years and have one son.
ImmunizationHistory:No explicit information apart from immunization for tuberculosis andwhooping cough
SignificantFamily History:His father suffered from the same condition in his early twenties,his mother died of hypertension.
Lifestyle:Does not smoke or drink
Reviewof the System:He regularly experience appetite and weight loss.
OBJECTIVEDATA
PhysicalExam:
VitalSigns: Weight: 110 pounds Temperature: 42oC Pulse: 47 RESPIRATIONS 12 breaths per minute BMI 24 HEIGHT5” 8 BP: 150/70
General:The patient is well groomed but in an erratic mood. He is unfamiliarwith the inflammatory. The patient is well groomed but in an erraticmood. He is unfamiliar with the inflammatory bowel diseases. Theexamination entailed examination of neck, mouth, abdomen andexamination of liver and gallbladder. As part of insurance there willbe cardiac and lungs.
ASSESSMENT
Onconducting a physical assessment, the patient looked clearly unwell,febrile, tachycardia, pale, and dehydrated. Through this it is easierto extract abnormal findings from physical exam. Finally it is theneasy to infer diagnoses as required. It turns out that the patient issuffering from ulcerative colitis because of the dehydrated nature aswell as tachycardia condition (Miller,2015).Another possibility is the Crohn’s disease since its signs resemblethat of the ulcerative colitis especially in consideration that thepatient has been experiencing bloody diarrhea.
PLAN
TreatmentPlan:The patient should use 5-ASA agents in the hope of inducing remission
HealthPromotion:The therapy comprising of oral or topical 5-ASA agents or both isefficient for both active colitis and for maintaining remission.Additionally, it is superior to rectal corticosteroids for distaldisease (Lichtenstein&Scherl, 2010).Alternatively, I recommend a surgical removal of the colon since itis the only practical option to heal the ulcerative colitis becausethere is no curative medicine for it (Jewell,2006).
DiseasePrevention:Dietary changes might help to reduce ulcerative colitis signs. Thesymptoms of an individual depends largely on the symptoms of theperson’s symptoms, food reactions, and medications. The mostrecommended tips for a diet that lessen signs include reducing theconsumption of carbonated drinks, consuming foods presumed to beinsipid, and reducing the foodstuffs that have more fibers (Velayos,2014).
REFLECTION
Fromthis exercise, I have learned that it is essential to have abackground of various diseases. Further, from the assessment, I wouldcarry out detailed genetic assessments of the patient. When taking upthe subjective data, I would try to relate every other part and theneliminate any error that might be captured. I would not just notethem down and relax. From the evidence that I have gathered, I tendto disagree with the preceptor.
References
Jewell,D. P. (2006). Colitis:Diagnosis and therapeutic strategies.Dordrecht: Springer.
Lichtenstein,G. R., & Scherl, E. J. (2010). Ulcerativecolitis: The complete guide to medical management.Thorofare, NJ: SLACK.
Miller,E. (2015). Ulcerativecolitis: Genetics to complexities.Place of publication not identified: Foster Academics.
Velayos,F. (2014). Chemoprevention in Ulcerative Colitis. MedicalTherapy of Ulcerative Colitis,14(3),247-296.