SOAP NOTE #2

Name: Ira Doe

Date: 10-31-2019 Time: 8:50am Birthdate: March 28, 1947

Age: 72 Gender M   F  Marital Status S  M  D  W 

Lives With: Wife

Occupation: Retired Actor

Source of history: Patient

Source of referral: Self-referred

Reliability: Reliable

Chief Complaint:

“I’ve been having abdominal pain since last night.”

History of Present Illness

Mr. Ira presents to the office today reporting abdominal pain since last night. He states
the pain began after a large meal of “pasta and meatballs” and has been constant since
dinner. He admits one episode of nausea and a small amount of vomiting after his meal
last night, followed by one instance of a loose bowel movement. He rates the pain 8/10 at
rest and denies any relieving factors. He identifies the pain as being located in the “right
upper area” and gestures over the right 10-12 intercostal spaces extending into the RUQ.
He states that the pain also radiates to below his right scapula area. He states that he has
had pain resembling this occurrence one time approximately a year ago after eating a
large meal, but “nothing as bad as this is”.

Medications:
Zocor 20 mg nightly
TriCor 145 mg daily
Diovan 160 mg daily
ASA 81 mg daily
Fish oil (4 tabs) OTC
Tylenol sometimes- “I can’t take Advil”
Adherence with all meds
Patient denies any recent changes in medications, denies use of herbal supplements.

Allergies:
No known diagnosed allergies.
Tobacco:
Nonsmoker-quit 12 years ago. 100 pack year history.

Social:
Denies any recreational drug use. Drinks alcohol rarely. Lives with wife who is in good
health. He is a retired actor.

Past History:

Childhood Illnesses: None.

Adult Illnesses: Hypertension treated for last 3 years, hypercholesteremia/elevated
triglycerides treated for last 25 years.
Medical: No prior hospitalizations.
Surgical: Aortic valve replacement 12 years ago. Right hip replacement 1 year ago. No
additional hospitalizations, no noted complications.

Family History:

Mother – Deceased. Hemorrhagic stroke. Diabetic.

Father – Deceased. Hypercholesteremia.
Brother – No known illnesses.

Personal and Social History:

Patient is retired, lives at home with wife who is in good health. Reports moderate dietary
adherence. One sexual partner being wife. No history of STIs. Up to date on all
vaccinations including flu and pneumonia.

Review of Systems:
General: Negative for weight loss, fever, chills. Patient appropriately groomed and
dressed, well nourished. Appears to be in a moderate amount of discomfort.
Neurological: Denies blurry vision, dysphagia, vertigo, ataxia. No headaches reported.
No numbness, tingling, seizures, or memory loss.
HEENT: Negative for any head trauma, normocephalic. Denies neck stiffness or pain.
Denies photophobia, sinusitis, rhinitis. Negative for tinnitus. No vision changes.
Cardiac: Denies chest pain, palpations, or dyspnea on exertion. No edema.
Pulmonary: Negative for shortness of breath, wheezing, cough, or expectorated sputum.
GI: Negative for melena, hematemesis. No change in bowel habits outside of one episode
of vomiting and diarrhea noted in HPI. He denies any history of GERD, or recurring
epigastric pain.
GU: Denies dysuria, frequency, hematuria, or incontinence.
Integumentary: Diffuse ecchymosis on bilateral arms and legs. Denies any pruritis. No
jaundice, no lesions.
Musculoskeletal: Denies abnormal gait, weakness, or musculoskeletal injuries. No
swelling, cramps, atrophy, or stiffness.
Vital Signs:
T 98.0F, HR 78 , RR 16, BP 140/82, BMI 30

PE: (focused)
General: A&O x 3. Appears to be in a moderate amount of physical distress; leaning
forward and abdominal guarding. Otherwise well-nourished and dressed appropriately.
Skin: Warm, dry, intact, elastic. No jaundice, cyanosis, abnormal lesions or rashes. Pt has
diffuse areas of ecchymosis on upper and lower extremities bilaterally. Hair distribution
is regular.
HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular
movements intact, no nystagmus. Tympanic membrane intact, translucent gray with +
light reflex. No sinus tenderness, no lymphadenopathy. Nasal mucosa pink, with no noted
discharge, upper and lower turbinates visible with no swelling. Septum midline. Tonsils
visualized, no erythema in pharynx, no lesions or patches in oral musoca. No abnormal or
missing dentation. Gums pink, no hyperplasia, no bleeding.
Heart and Lungs: Lung sounds clear in all lobes to auscultation. Brief S1, S2 noted with
faint systolic murmur at right second intercostal space. No extra heart sounds present.
Rhythm regular. No edema.
Abdomen: + Murphy’s sign, + Boas point. + Bowel sounds in all quadrants. No
abdominal distention, no rigidity. No rebound tenderness. Guarding present upon
palpation of RUQ. Negative obturator; psoas sign, negative Rovsings sign. Percussion of
liver reveals a width of 8cm at right midclavicular line.
Neuro: No change in sensation. Deep tendon reflex +2 bilaterally.
Extremities: Warm, no edema, no joint swelling. Muscle strength of arms, shoulders, legs
and hands +3 bilaterally.

Differential Diagnoses:

1. Cholecystitis (acute) ICD-10 K81.0

Rationale: This is most likely the appropriate and working diagnosis. Acute
cholecystitis is most commonly diagnosed by presence of upper right quadrant
pain, radiating to right shoulder in some patients. This is differentiated from
biliary colic by the presence of constant pain for greater than 6 hours, as opposed
to intermittent pain usually experienced in biliary colic (Bloom, 2019). A positive
Murphy’s sign is indicative of acute cholecystitis with a specificity of 79% - 96%
(Miura, et al., 2013). Acute cholecystitis is often precluded by a fatty meal,
accompanied by nausea and vomiting, and has a higher incidence in patients
taking cholesterol lowering drugs (Cash & Glass, 2017).

2. Unspecified acute appendicitis ICD-10 K35.80

Rationale: This diagnosis should be considered given the presence of abdominal
pain and vomiting which is present in 75% of cases. If the appendix is in an
atypical position, which is more common in adults >60 years old; pain may
present in a displaced area (Epocrates, Inc., 2016). This diagnosis is less likely
given negative obturator, psoas, and Rovsings signs. Pain from acute appendicitis
 most commonly begins in the peri-umbilical area, then shifts to the right lower
quadrant after 6-12 hours (Cash & Glass, 2017).

3. Acute pancreatitis ICD-10 K85

Should be considered in the differential given the presence of abdominal pain,
nausea and vomiting. This is less likely to be the correct diagnosis as acute
pancreatitis usually presents as a “knife-like” pain that radiates to the back and
worsens with movement. It is also more common after an average of 4-8 years of
regular alcohol intake (Epocrates Inc., 2016), which the patient denies.

4. Peptic ulcer disease (PUD)/ perforation ICD-10 K27.1

May be considered as the patient states he “cannot take Advil”, an NSAID that is
common in causing PUD. The presence of abdominal pain, nausea and vomiting
also provide for inclusion. This diagnosis is unlikely, though because it is usually
experienced as recurrent epigastric pain which the patient denies. It is also often
accompanied by hematemesis and/or melena which the patient also denies.

Assessment and Plan:

1. Cholecystitis (acute) ICD-10 K81.0

a. Considering the patient’s age and risk factors, an admission to the
emergency room for a possible surgical consultation would be advised
rather than a referral to gastroenterologist and ordering outpatient lab work
and ultrasound.
b. Laparoscopic cholecystectomy is the standard of care for the surgical
treatment of cholecystitis. Zafar et al report the best patient outcomes and
economic approach being achieved through laparoscopic cholecystectomy
performed within two days of presentation of acute cholecystitis (Zafar, et
al., 2015).
c. Instruct patient to remain NPO until arrival at ER.
d. Ultrasonography is the recommended diagnostic tool to identify acute
cholecystitis. Sonographic Murphy’s sign may be elicited to further
confirm diagnosis.
e. If indicated, a HIDA scan may be performed in the event of poor
visualization on ultrasound.
f. Empiric antibiotic recommended by the Sanford Guide are as follows:
Piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV q8h); or
Ertapenem 1 gm IV q24h (Antimicrobial Therapy, Inc., 2019).
g. Initial laboratory testing to include CBC w/diff, CMP, AST, ALT,
bilirubin, and urinalysis to rule out pyelonephritis and renal calculi. Stool
guaiac may also be performed.
h. EKG to rule out cardiac involvement.
i. Tylenol extra strength may be used as needed for pain. Do not exceed
1G/4 hours and 4G/day. Avoid Advil and NSAIDs due to patient provided
history of not being able to tolerate.
 j. Recurring nausea and vomiting may be treated with Promethazine 25mg
PO every 6 hours.
k. Schedule follow up appointment with patient after discharge from
hospital. Educate on dietary adherence and lifestyle changes including
exercise, weight loss, and reduction in fatty foods.
2. Hypertension (primary) ICD-10 l10
a. Continue with Diovan 160mg daily. Advised of side effects.
b. Re-measure blood pressure at follow-up visit and teach patient how to
self-monitor blood pressure and keep a log. This is to rule out pain being
the exacerbating cause of this visit’s elevated blood pressure and evaluate
for further intervention.
c. If patient exhibits sustained hypertension, consider increasing Diovan to
320 mg daily.
d. Examination of optic fundi for retinopathy or cotton-wool patches and
ophthalmologist referral as appropriate.
e. Educate patient on heart-healthy diet and benefits of exercise and weight
loss.
3. Mixed hyperlipidemia ICD-10 E78.2
a. Continue Zocor and Tricor daily. Advised of adverse effects and s/s
rhabdomyolysis.
b. Therapeutic lifestyle changes are recommended. The goal is to reduce
intake of saturated fats to <7% of total calories and cholesterol to <200
mg/day, increase physical activity, and promote weight loss (Epocrates
Inc., 2016).
c. Baseline lipid profile to be obtained to assess efficacy of current regimen.
d. If current lipid profile not within target range, repeat panel every 6 weeks
while titrating medication to achieve desired LDL and triglyceride levels.
e. Once target levels achieved, interval may be extended to every 6-12
months in patients adherent to lifestyle modifications (Epocrates Inc.,
2016).
4. Health promotion
a. Regular BP monitoring, colon cancer screening, prostate exams,
sunscreen, safety belts.
b. Recommend continued adherence with yearly influenza vaccine

Problem List:
1. Cholecystitis (acute) ICD-10 K81.0
2. Hypertension (primary) ICD-10 l10
3. Mixed hyperlipidemia ICD-10 E78.2 Mild intermittent asthma, uncomplicated
(controlled) ICD-10 J45.20
 References:

Antimicrobial Therapy, Inc. (2019). The Sanford Guide to Antimicrobial Therapy (3.0.4)
[mobile application software]. Retrieved from
https://apps.apple.com/us/app/sanford-guide-antimicrobial/id863196620.

Bloom, A. A. (2019, October 20). Cholecystitis Clinical Presentation: History, Physical

Examination. Retrieved from https://emedicine.medscape.com/article/171886-
clinical.

Cash, J. C., & Glass, C. A. (2017). Family practice guidelines. New York: Springer
Publishing Company, LLC.

Epocrates, Inc. (2016). Epocrates Plus (19.10.1) [mobile application software]. Retrieved
from https://apps.apple.com/us/app/epocrates/id281935788.

Miura, F., Takada, T., Strasberg, S. M., Solomkin, J. S., Pitt, H. A., Gouma, D. J., …
Liau, K.-H. (2013). TG13 flowchart for the management of acute cholangitis and
cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences, 20(1), 47–54. doi:
10.1007/s00534-012-0563-1

Zafar SN, Obirieze A, Adesibikan B, Cornwell EE 3rd, Fullum TM, Tran DD. Optimal
time for early laparoscopic cholecystectomy for acute cholecystitis. JAMA Surg.
2015 Feb. 150(2):129-36.