SOAP Note: Ulcerative Colitis

SOAP Notes: Ulcerative Colitis
Student’s Name
Institutional Affiliation
SOAP Notes: SOAP Notes: Ulcerative Colitis
Patient X is a 34-year-old white female who reports to the clinic with complaints of acute abdominal pain, epigastric, and blood-stained stool after meals.
Subjective Data:
Chief Complaint (CC)
The patient reports acute abdominal pain, epigastric pain, diarrheal episodes post-meals, and blood-stained stools.
History of Present Illness (HPI)
The 34-year-old patient presented the acute symptoms of abdominal pain, epigastric pain, episodic diarrhoea for one week. she decided not to seek care because she hoped her symptoms would disappear. she ate pizza on Tuesday, which was followed by diarrhoea. The next day, she ate salmon burgers, which were followed by bouts of diarrhoea, and the following day, she ate chicken and broccoli, which led to another bout of diarrhea. She currently cooks at home and not eating out. She reports some blood and mucous in stool. she also has nausea, pain on a scale of 9/10. The pain is aggravated by eating and relieved by diarrhea or taking bland food. She denies any history of recent travel.
Medical history:
* Mastitis
* Herpes
* Dermatitis
* No history of hospitalization
Surgical history
No history of injuries and surgeries
Family history:
* Her father had depression and hyperlipidemia
* Her mother had depression and diagnosed with breast cancer at age 64
* Her sister is healthy
* Her deceased paternal grandfather had a heart problem and lung cancer
* Her deceased paternal grandmother was healthy
Social History:
A 34-year-old female with no children
Current Medications
* Desogestrel (Ethinyl estradiol) 0.15-0.30mg PO daily
* Diclofenac 75mg PO daily BID
* Lamotrigine 100mg one tablet daily
* Gabapentin 300mg tablet PO TID
* Levocetirizine 5mg daily 4mg
* Ondansetron 8 hourly when necessary
Allergies
* The patient reports no current medications.
* She is allergic to aspartame (gastrointestinal reaction) and Neosporin (dermal reaction)
Review of Systems (ROS)
General: Denies weight loss
Skin: Denies any cyanosis or any other problem
Gastrointestinal: Reports abdominal pain, epigastric pain and blood-stained stool after meals
HEENT:
* Denies history of eye changes
* Denies any changes in vision,
* Denies any ringing in the ears, vertigo, and earache infection
Musculoskeletal
Denies any neck, back, and arm pain
Neurological
Denies any symptom including dizziness, lightheadedness, and fatigue
Hematologic
Denies any easy bruising or bleeding
Psychiatric
Denies any history of psychological disturbances or depression
Endocrinology
Denies cold intolerance, excessive thirst and any abnormal sweating
Objective Data:
* Vital signs: BP 138/86mmhg, pulse 94, Temp 98.0 weight 210 bounds, height 5’8
* Physical exam findings: Bloated abdomen
* Laboratory data: polymorphonuclear cells present upon staining
Systemic General Review
General observation: patient appears with no acute distress. She is well developed and nourished appropriately dressed to according n weather.
Skin
* Smooth, pale with normal hair distribution
* No wounds, scars and rashes
HEENT
* Normal hair distribution on scalp
* No scars and wounds on face or scalp
* No tenders on maxillary and frontal sinuses
* Eyes are symmetrical with no discharge
* No discharge in the ears
* Trachea is midline
* The thyroid is normal upon palpation
* Tonsils are not enlarged
* No cervical lymphadenopathies
Cardiovascular
* S1 at the apex and S2 at the base of the heart
* No S3 and S4
* No heaves or thrills
* No carotid bruits
* HR 98 beats per minutes/regular
Chest and Lungs
* Symmetrical chest expansion
* No deformities, scars and retractions observed
* No masses upon palpation
* Equal tactile fremitus and resonant upon percussion
Abdomen
* The abdomen is soft with no palpable lymphadenopathies
* The abdomen is tender in the periumbilical area.
* No bruits at abdominal aorta
* Bowel sounds are active upon auscultation
* There is tympany throughout the abdomen
* The liver is 7 cm below MCL and 1mc below the right costal margin
* Spleen and bilateral kidneys are not palpable
Musculoskeletal:
* All muscle bilateral UE and LE are graded 5/5
* No joint deformities
* Good range of motion in hands, wrists, elbows, shoulders, spine, knees, and ankles.
Peripheral vascular and extremities
* No edema
* Bilateral, radial, femoral, and dorsalis pedis pulses are non-bounding with a regular rhythm
* The capillary refill of bilateral middle and index fingers is about 2cm.
Neurological
* No deficit
* Oriented to place, time, and space
Assessment
The symptoms reported by the patient such as abdominal pain, epigastric pain, nausea and, diarrhoea after meals can imply gastrointestinal disorder. The patient reports bland food as a core reliever to her symptoms. A bland diet can provide a clue in diagnosing the disorder in this case.
The bland diet is an adjunct to lifestyle modifications and intervention for patients struggling with gastric or duodenal ulcers, inflammatory bowel disease such as ulcerative colitis, gastroesophageal reflux disease (GERD), flatulence, food poisoning, traveller's diarrhea, inflammatory bowel disease, diverticulosis, gastroenteritis heartburn (Weir & Akhondi,2020).
Differential Di...