Assignment: Plausible Differential Diagnosis SOAP NOTE

Assignment: Plausible Differential Diagnosis SOAP NOTE

Assignment Plausible Differential Diagnosis SOAP NOTE

SUBJECTIVE:

CC– The patient states that, “I just have real bad pain in my lower stomach.”

HPI: MS, complains of having severe pain in her lower abdomen that has lasted for 2 days. The pain, however, does not radiate to the back or her legs. She claims that she doesn’t think it was brought about because of something that she ate. However, she has no difficulty in eating. She describes the pain as sharp and deep and makes her noxious. She states that she has vomited twice ever since the pain started, but denies blood in the vomit. Her body temperature is a bit elevated, 102^oF. The pain is worse when she stands up, walk or lie down and reduces when she is crawling. She has been taking Tylenol to manage the pain but claims that it has not been working. She claims that the pain has been constant for all the 2 days, and very intense, with a score of 10/10.

• Onset – 2 days ago
• Location- lower abdomen
• Duration – 2 days
• Character – sharp, deep, and nauseating
• Aggravating factors – standing up, walking or lying down
• Alleviating factors – crawling
• Radiation – does not radiate to the back or her legs. Just the lower abdomen.
• Timing – the pain has been constant for the 2 days.
• Severity – 10/10 on the pain scale

PMH:  Painful periods, unmanaged for the past 2 months.

PSH: Denies ever having any surgery.          

Medications:

OTC – Tylenol 500mg PO

Ortho-Cyclen (28) Oral – but she has not taken then in 2 months.

Allergies: NKDA.

FMH:

Mother: Alive, age 45, with a history of high blood pressure and high cholesterol. Had a history of hysterectomy due to ovarian cancer.

Father: Alive, age 45, has type II Diabetes

Sister: Alive and healthy

Brother: Alive, has bipolar disorder.

Maternal grandparents:

Grandmother died at age 60 from breast cancer

Grandfather, alive, age 65, has high blood pressure and high cholesterol

Does not know the medical history of paternal grandparents.

SH: Sexually active, with only one partner in a serious relationship and, uses condoms occasionally. Denies any history of smoking or using any illicit drugs. Drinks a few glasses of alcohol occasionally, once a week. Goes to school, and is still an active church member. No new hobbies or new diet.

ROS: 

General: denies having any problems with weight gain, weight loss, or dizziness. Denies any problems with night sweats.

Skin: denies any itching or dryness of the skin around the abdomen.

Eyes: normal pink conjunctiva. Equal dilation of pupils.

Ears: denies any ear pain or discharge. Can hear without aides.

Nose\Mouth\Throat: Throat in good condition. No redness.

Neck: Denies any problems with the neck on palpation.

Cardiovascular: Denies any history of heart problems or chest pain. Heart in good condition, no signs of skip beats, no S3 sounds.

Respiratory: Denies any shortness of breath, or coughing at present. No crackles or wheezes on the lungs.

Gastrointestinal: Reports sharp pain on the lower abdomen when taking deep breaths. Pain on palpation of the lower abdomen.

Genitourinary: Denies any pain upon urination. Denies urine discoloration. Reports presence of a normal clear thin white vaginal discharge.

Musculoskeletal: Denies any muscle or joint pain. Reports normal exercise frequently.

Psychological: Denies any problems with mental thoughts, mood, anxiety, stress, depression. Denies any problems with excessive drinking.

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OBJECTIVE DATA

Physical examination

VS: Temp 102^oF

BP: Normal

General appearance: appears to be in so much pain. Stable mood and able to answer all the questions without hesitation. Well-groomed and in the right state of mind.

Skin: no signs of lesions, or rashes on the skin. She has healthy skin.

HEENT: the head appears normocephalic. Eyes: normal pink conjunctiva. Equal dilation of pupils. Ears: very clean. No signs of exudates noted. Nares: no signs of nasal drainage or swelling. Oropharynx: good dentition, no erythema or lesions, clear tongue with no clouding. No signs of tonsillar swellings.

Neck\Lymphatic: Neck: uniform skin complexion. No signs of inflammation. No signs of lymphadenopathy on palpation.

Cardiovascular: Regular heart sounds and rhythm. S3 absent but S1 and S2 present. No heart murmurs noted. No carotid bruits heard.

Respiratory: breaths perfectly with no difficulties. Lung sounds are normal on auscultation, anteriorly, bilaterally and posteriorly.

Gastrointestinal: sharp pain on the right lower quadrant on palpation. Elicit Rovsing’s sign on deep palpation of the lower left quadrant.

Genitourinary: Normal genitally noted with no signs of herniation.

Musculoskeletal: lower abdominal pain when psoas sign in performed with the patient flexing the right thigh against the physicians resisting arm. Upon performing obturator sign by flexing the right hip and knee of the patient to 90^o there is a sharp pain in the right lower quadrant of the abdomen.

Psychological: Maintains good contact while answering all the questions. Seems calm, and responsive through all the physical examination. Does not seem stressed or anxious.

Diagnostics:

1. Rovsing’s sign
2. Obturator sign
3. Psoas sign

Student expectations:

ASSESSMENT

• Abdominal pain
• Differentials –:

1. Acute appendicitis: Positive Rovsing’s sign to the right lower quadrant and obturator sign by flexing the right hip and knee of the patient to 90° suggests acute appendicitis.
2. Pelvic abscess: positive psoas sign, lower abdominal pain suggests psoas abscess.
3. Diverticulitis: positive psoas sign, lower abdominal pain, suggest diverticulitis.

PLAN

The patient requires further pelvic examination for a proper diagnosis to assess for any potential gynecological pathology before deciding on the course of treatment.

Differential Diagnosis Illness Script

Illness Scrip	Differentiate #1         Acute appendicitis
Epidemiology	Acute appendicitis in the United States is one of the most common causes of acute surgical abdominal emergencies. Every year, approximately over 250,000 appendectomies are performed by physicians in America. Nonetheless, the incidence is minimal in areas where people consume high-fiber diets. Among males, the overall lifetime risk of one developing acute appendicitis is approximately 8.6%, but lower in females, 6.7%. consequently, the lifetime risk of undergoing an appendectomy is about 12% in males and higher in females, 23%. In the US, appendectomy rates are about 10 per 10,000 cases every year. Acute appendicitis is most common among teenagers and those in their late 40s. Additionally, there is a slight male to female predominance of about 1.3:1 (Jangland, Kitson, & Muntlin, 2016).
Time Course	The time course of acute appendicitis from the onset of the sign and symptoms to rupture is usually 12 hours to several days.
Clinical Presentation	The most common clinical presentation of acute appendicitis is abdominal pain. Initially, the pain is usually peri-umbilical and poorly localized. But with time the pain radiates to the right iliac fossa, where it becomes sharp, localized and persistent. Other symptoms include nausea and vomiting, diarrhea, constipation, and anorexia (Jangland, Kitson, & Muntlin, 2016). Additionally, the patient is usually positive for Rovsing’s sign and Psoas sign.
Pathophysiology	Appendicitis presents when there is an acute inflammation of the appendix. The main cause of the inflammation is not clear; however, it is suspected that when the lumen of the appendix becomes blocked by normal fecal matter, a faecolith, or lymphoid hyperplasia as a result of a viral infection. The obstruction reduces the flow of blood to the tissue and hence allowing for bacterial multiplication (El-Radhi, 2015). The obstruction also results in an increase in the pressure within the appendix reducing venous drainage and hence resulting in ischemia. If untreated, the ischemic condition might lead to gangrene or necrosis.
Lab	Urinalysis needs to be done for all patients suspected of appendicitis to rule out UTI among other renal/urological cause. Pregnancy test for all women of reproductive age is also essential. Routine blood tests, mainly FBC and CRP are important especially in assessing elevated inflammatory markers. A baseline blood test is mainly important for preoperative assessment (Mayumi et al., 2016). Serum β-Hcg can also be taken in case ectopic pregnancy has not been ruled out.
Imaging	Imaging is not very necessary in the diagnosis and treatment of acute appendicitis, as most cases are usually clinically diagnosed. However, a CT scan or trans-abdominal ultrasound can be done in case of inconclusive clinical features.

 

 

Illness Scrip	Differentiate #2         Pelvic abscess
Epidemiology	A pelvic abscess is a very rare condition. However, some of the main predisposing factors that can result in pelvic abscess include Crohn’s disease, immunodeficiency, pregnancy, and diabetes mellitus. In the case of Crohn’s disease, the abscesses may occur either as a complication of surgery or spontaneously (Mui, Allaire, Williams, & Yong, 2016).
Time Course	May take days for the pelvic abscess to grow quite large before the onset of the symptoms.
Clinical Presentation	The condition presents with systemic features of toxicity such as malaise, fever, anorexia, nausea and vomiting and pyrexia. Some of the local effects as a result of a pelvic abscess include deep pain and tenderness in a single or both of the lower quadrants, tenesmus, diarrhea, dysuria and mucous discharge per rectum (Kelly, Cullmann, Puig, & Applegate, 2018).). Upon rectal examination, tenderness may be revealed on the pelvic peritoneum.
Pathophysiology	Pelvic abscess usually occurs as a result of gynecological procedures or infections, or acute appendicitis. It can also present as a complication of diverticulitis, Crohn’s disease or abdominal surgery. The abscess contains pus or infected fluid walled by an inflamed tissue (Yosef et al., 2016). In males, the abscess is usually situated between the rectum and the blooder. In females, the abscess is usually between the posterior fornix of the vagina and the uterus and the rectum posteriorly. Women of productive age usually develop tubo-ovarian abscess that may be a complication of an inflammatory pelvic disease.
Lab	FBC: which usually shows raised white blood cell count.
Imaging	Ultrasound or CT/MRI scan to locate the origin of the abscess.

 

 

Illness Scrip	Differentiate #3         Diverticulitis
Epidemiology	Diverticulitis is a very common condition of the colon in developed countries. Westernized countries have a very high prevalence of the left-sided diverticulitis. The right-sided diverticulitis is very rare but mainly experienced in the Asian countries, where the prevalence is also very low (Tursi et al., 2014). Prevalence of diverticulitis, however, increases with increase in age, but most cases are reported among the aged, 80 years and above. The prevalence in women is however equal to that of men.
Time Course	Most patients are asymptomatic but symptoms might take days to weeks to appear.
Clinical Presentation	The main clinical presentation of diverticulitis is severe abdominal pain, and cramping which is usually worse on the lower left abdomen, and increases on pressure (Tursi et al., 2014). Other symptoms include nausea and vomiting, fever, bloating, thin stool or constipation or diarrhea.
Pathophysiology	Normally, the development of diverticula in the colon occurs in adjacent rows between the taenia coli. Pathophysiological understanding of diverticulitis involves three main areas, the structural abnormalities of the walls of the colon, intestinal motility disorders, and dietary fiber deficiency. However, there are some factors such as inflammation, use of NSAIDs, smoking, obesity and alcohol intake which can also result in diverticulitis (Tursi et al., 2014).
Lab	Stool test, liver enzyme test, pregnancy test for women of productive age, blood and urine tests.
Imaging	CT scan or X-rays of the abdominal region is usually the main diagnostic criteria for diverticulitis (Poletti et al., 2017). Colonoscopy.

 

Students will watch the video and:
1. Complete the SOAP documentation.
2. Describe 3 of the most plausible differential diagnosis. Rule-in and Rule-out each diagnosis. Example: If a patient presents with a painful knee and your top differentials are osteoarthritis, ACL, and Fracture, you would find peer-reviewed Evidence to prove that each of those are possible diagnosis. For osteoarthritis: Rule in: What signs and symptoms match what the patient has. Give the evidence (from peer reviewed based information) to show that the symptoms match. Then rule out: What is lacking to show this is the actual diagnosis? You must demonstrate your thoughts with peer reviewed evidence.
3. Complete the Illness script.
4. Include a reference page

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Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

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Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

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Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed
• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• Student paper example
• Citing Sources
• The Writing Center is a great resource