NU 685 SOAP Note IV (Focused SOAP NOTE)

(Subjective) Chief Complaint: “I still have rectal bleeding”

History of Present Illness: A 68-year-old male presents to the office today following a recent hospital discharge on February 13 due to complaints of blood in stool and diarrhea persisting for 5 days. The patient reports that he continues to experience blood in his stool. During the hospitalization, an abdominal X-ray, transfusion of 2 units of packed red blood cells, colonoscopy, and endoscopy were performed, yet the source of bleeding remained unidentified. The patient reports an appointment with a gastroenterologist yesterday and plans for further evaluation with a capsule endoscopy. The patient currently has two bowel movements daily, each accompanied by a moderate amount of blood on soft stool. He denies vomiting, diarrhea, weakness, dizziness, pain, or body aches.

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Past Medical History: Hyperlipidemia (HLD), Coronary Artery Disease (CAD), Hypertension (HTN), Gastroesophageal Reflux Disease (GERD), Hemorrhoids, Prostate Cancer

Past Surgical History: Coronary Artery Bypass Graft (CABG), Pacemaker placement (10 years ago), Radical prostatectomy (3 years ago)

Current Medications:
1. OMEPRAZOLE 40 MG, 1 delayed-release capsule daily for GERD
2. ASPIR-LOW 81 MG, 1 delayed-release tablet daily for CAD
3. COREG 25 MG, 1 tablet twice daily for CAD
4. GEMFIBROZIL 600 MG, 1 tablet twice daily for HLD
5. VITAMIN D3 50,000 INTERNATIONAL UNITS, 1 capsule weekly for Vitamin D Deficiency

Social History: Former smoker, quit 15 years ago

Allergies: Tylenol-codeine (causing rash and muscle spasms)

Family History: Father deceased due to liver cirrhosis at 85 years old, mother deceased (status unknown)

REVIEW OF SYSTEMS

Constitutional: The patient denies fatigue, pain, fever, heat intolerance, weight gain, weight loss, night sweats, cold intolerance, and poor appetite. The patient acknowledges rectal bleeding.

Skin: The patient denies skin and hair changes or rash.

Eyes: The patient denies cataracts, blurry vision, glaucoma, double vision, puffiness of eyelids, eye pain, eye redness, eye discharge, and eye itching.

Ears, Nose, Throat: The patient denies ear pain, nasal congestion, hearing difficulties, discharge, hoarseness, postnasal drip, dry cough, productive cough, eye redness, and lymph node enlargement.

Respiratory: The patient denies hemoptysis, wheezing, snoring, or cough.

Cardiovascular: The patient denies palpitations, paroxysmal nocturnal dyspnea, peripheral edema, venous thrombosis, chest pain/discomfort, dizziness, diaphoresis.

Endocrine: The patient denies heat and cold intolerance.

Gastrointestinal: The patient reports dark bloody bowel movements twice daily, denies gas and bloating, has two bowel movements daily, soft and moderate in amount, and denies constipation, vomiting, and dysphagia (difficulty swallowing).

Genitourinary: The patient reports a change in the force of urination, has a history of Prostate Cancer, reports some incontinence or dribbling, denies hematuria, discharge, flank pain, and polyuria.

Immune/Lymph: The patient denies lymph node enlargement and lymph node tenderness.

Musculoskeletal: The patient denies back pain, rash, redness, limited range of motion, joint pain, arthritis, cramps, stiffness, and numbness.

Neurology: The patient denies balance/gait problems, headache, neck stiffness, seizures, weakness, visual changes, loss of consciousness, speech impairment, and numbness/tingling.

Psychiatric: The patient denies depression, memory loss or confusion, nervousness, anxiety, insomnia, crying spells, auditory hallucinations, and a history of drug abuse/painkillers.

(Objective) /PHYSICAL EXAM

Vital Signs: BP: 107/65 (sitting); Pulse: 60 /min; O2 Sat 98% (on room air); Weight: 165lb; Height: 5 feet 8 inches; BMI: 25.1; CBG: 108

Urinalysis: pH: 6.0; Specific Gravity: 1.020; Protein: Negative; Glucose: Negative; Ketones: Negative; Urobilinogen: 0.2; Blood: Negative; Nitrites: Negative; Leukocytes: Negative

Urine Toxicology: Appearance: In no apparent distress; Well-developed, well-nourished, well-groomed, not distressed

Skin: No lesions/rash/visible abnormalities, warm to the touch, good turgor

Head: Normocephalic and atraumatic

Eyes: Extraocular movements intact, pupils equal, round, and reactive to light and accommodation, sclera clear, conjunctiva non-injected

Ears: No redness/swelling, ear canal is clear with no visible discharge, tympanic membrane intact

Nose: Moist mucosa with no septal deviation

Neck: Supple, no lymphadenopathy, no jugular venous distention, thyroid non-enlarged

Throat: Moist mucosa, no exudates/ulcers/congestion, tonsils not enlarged, uvula midline

Respiratory: No hemoptysis, wheezing, snoring, or cough. Breath sounds clear bilaterally.

Cardiovascular: Regular rate and rhythm, no murmurs, gal

lops, or rubs. Peripheral pulses palpable.

Abdomen: Soft, nontender, non-distended. Bowel sounds present. No rebound or guarding. No organomegaly or masses.

Back: No redness or swelling. No paraspinal tenderness or spasm. Range of motion within normal limits. Straight leg raise test is negative.

Extremities: No erythema, swelling, warmth, or tenderness. Sensations intact bilaterally. Strength 5/5 bilaterally. Deep tendon reflexes 2+. Peripheral pulses 2+.

Musculoskeletal: Examination reveals full range of motion, symmetric strength, and normal muscle tone.

Neurological: Alert and oriented to person, place, and time. Cranial nerves II-XII grossly intact. Sensations intact. Muscle tone within normal limits. Strength 5/5 in all muscle groups. Deep tendon reflexes 2+. Cerebellar functions intact. Gait is normal.

Psych: Appropriate mood and affect. No delusions or suicidal/homicidal ideations.

Ext. Genitalia: Deferred

Rectal: Deferred

(Assessment)/ Test: CBC, CMP, EKG, ANEMIA, Hemoglobin A1c, LIPID PROFILE, PSA, Vitamin D Total

Diagnosis: Gastrointestinal Hemorrhage, Unspecified (ICD-10 code K92.2)
Gastrointestinal bleeding is a symptom of a disorder in the digestive tract. It can result in blood appearing in the stool or vomit, which may not always be visible but can cause the stool to appear black or tarry. The severity of bleeding can vary from mild to severe and may be life-threatening.

Differential Diagnosis: Peptic Ulcer Disease, Gastrointestinal Hemorrhage, Gastric Malignancy
Gastric Malignancy may cause significant bleeding, typically characterized by a more chronic and slower bleed. If occult blood or gastrointestinal bleeding is present, malignancy may be considered based on the presentation. Patients may exhibit a palpable mass, significant weight loss, or experience no pain with bleeding. Peptic ulcer disease, according to Mayo Clinic, refers to open sores that develop on the inside lining of the upper part of the small intestine. The most common symptom of a peptic ulcer is stomach pain.

Plan:
Gastrointestinal Hemorrhage, Unspecified: OMEPRAZOLE 40 MG delayed-release capsule once daily. Awaiting capsule endoscopy. Discontinue aspirin. Vitamin D supplementation with 50,000 IU capsule once a week.

Essential (primary) Hypertension: Continue with the same medications. Emphasize the importance of strict control and adherence to medication. Reduce sodium intake.

Malignant Neoplasm of Prostate: Continue with lifestyle modifications. Provide detailed counseling.

Referrals: Continue follow-up with GI, Urologist, and Oncologist.

Follow-up: Schedule a follow-up office visit in 2 weeks for review of lab results. In case of worsening bleeding, go to the ER.

(Subjective)   Chief Complaint: “I still have rectal bleeding” History of Present Illness:  68 -year old male presents to the office today, s/p hospital discharge on February 13 for blood in stool and diarrhea x 5 days. Patient reports still having blood in the stool.  Patient reports that while he was in the hospital an abdominal X ray, 2 units of pack red blood cell, colonoscopy and endoscopy were done, and they were not able to find the source of bleeding.   Patient reports seeing the gastroenterologist yesterday and will be following up for further studies with a capsule endoscopy. Pt reports 2 BMs daily, each time with moderate amount of blood on soft stool. Denies V/D/weakness/dizziness pain or body aches. Past Medical History:  HLD, CAD, HTN, GERD, Hemorrhoids, Prostate Cancer   Past Surgical History:  CABG, Pacemaker x 10 years, Radical prostatectomy 3 years ago Current Medications: OMEPRAZOLE 40 MG 1 delayed release capsule QD for GERD ASPIR-LOW 81 MG1 delayed-release tablet QD for CAD COREG 25 MG1 tablet BID for CAD GEMFIBROZIL 600 MG1 tablet BID for HLD VITAMIN D3 50,000 INTL UNITS1 capsule QWK Vitamin D Deficiency Social History:  former smoker, stopped 15 years ago Allergies: Tylenol-codeine, Symptoms: rash and muscle spasms Family History:  father- died due to liver cirrhosis at 85 y/o mother-deceased- status unknown  REVIEW OF SYSTEMS Constitutional: patient Denies Fatigue, Pain, Fever, Heat intolerance, Weight gain, Weight loss, Night Sweats, Cold intolerance, Poor appetite, Patient acknowledges bleeding from rectum. Skin: Denies skin, hair changes or rash Eyes: Denies Cataract, Blurry vision, Glaucoma, Double vision, Puffiness of eye lids, Eye pain, Eye redness, Eye discharge, Eye itching, Ears, Nose, Throat: Denies Ear pain, Nasal congestion, Hearing difficulties, Discharge, Hoarseness, Post nasal drip, Dry cough, Productive cough, Eye redness, Lymph node(s) enlargement, Respiratory: Denies Hemoptysis, Wheezing, Snoring, or Cough     Cardiovascular: Denies Palpitations, Paroxysmal nocturnal dyspnea, Peripheral edema, Venous thrombosis, Chest pain/discomfort, Dizziness, Diaphoresis, Endocrine: Denies Heat and cold intolerance, Gastrointestinal: Reports Dark bloody Bowel movement twice daily, Denies Gas and bloating,  BM X 2 daily, soft and moderate amount, No constipation, vomiting, dysphagia (difficulty swallowing), Genitourinary: Reports Change in force of strain when urinating patient has history of Prostate Cancer, Reports some Incontinence or Dribbling, Denies Hematuria, Denies Discharge, Flank pain, , Polyuria, Immune/Lymph: Denies Lymph node enlargement, Lymph node tenderness, Musculoskeletal: Denies Back pain, Rash, Redness, Limited range of motion, Joint pain, Arthritis, Cramps, Stiffness, (WNL) Multiple joint pains, Numbness, Neurology: Denies Balance/gait problems, Headache, Neck stiffness, Seizures, Weakness, Visual changes, Loss of conciousness, Speech impairment, Numbness/Tingling, Psychiatric: Denies Depression, Memory loss or confusion, Nervousness, anxiety, Insomnia, Crying spells, Auditory hallucinations, History of drug abuse/pain killers,   (Objective) /PHYSICAL EXAM Vital Signs: BP: 107/65 (sitting); Pulse: 60 /min; O2 Sat 98% (on RA) Weight: 165lb; Height: 5 feet 8inches; BMI: 25.1 CBG: 108; Urinalysis: pH: 6.0 SpecificGravity: 1.020 Protein: Neg Glucose: Neg Ketones: Neg Urobilinogen: 0.2 Blood: Neg Nitrites: Neg Leukocytes: neg Urine Toxicology:  Appearance: In no apparent distress Well developed, well nourished, well groomed, not distressed Skin: No lesion/rash/visible abnormalities, warm to touch, good turgor Head: Normocephalic and atraumatic Eyes: EOMI, PERRLA, sclera clear, conjunctiva non-injected Ears: No redness/swelling. Ear canal is clear with no visible discharge. TM intact. Nose: Moist mucosa with no septal deviation Neck: Supple. No LAD/JVD/Thyromegaly. Trachea midline. Throat: Moist mucosa. No exudates/ulcers/congestion. Tonsils not enlarged. Uvula midline Respiratory: No hemoptysis, wheezing, snoring, or cough. BL lungs clear CV: RRR, S1+S2+0. No murmur/gallop/rub Abdomen: Soft, nontender, non-distended. Positive bowel sounds. No rebound/guarding. No organomegaly/mass/ascites. Back: No redness/swelling. No paraspinal tenderness/spasm. ROM WNL. SLR negative. Extremities: No erythema/swelling/warmth/tenderness. Sensations intact bilaterally. Power 5/5 bilaterally. DTR 2+. Peripheral pulses 2+ Musculoskeletal: Exam reveals full range of motion, symmetric strength, and normal muscle tone. Neurological: AAOx3, CN2-12 grossly intact, sensations intact, muscle tone WNL, power 5/5 in all muscle groups, DTR 2+, cerebellar functions intact, gait normal Psych: Appropriate mood/affect, no delusions, no suicidal/homicidal ideations Ext. Genitalia: Deferred Rectal: Deferred  (Assessment)/ Test: CBC, CMP, EKG, ANEMIA, Hemoglobin A1c, LIPID PROFILE, PSA, Vitamin D Total Diagnosis: Gastrointestinal Hemorrhage, Unspecified K92.2 GI bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit but isn’t always visible, though it may cause the stool to look black or tarry. The level of bleeding can range from mild to severe and can be life threatening Differential Diagnosis: Peptic Ulcer Disease, Gastrointestinal Hemorrhage, Gastric Malignancy     Gastric Malignancy:  May cause major bleeding, however will typically have more chronic slower bleed.  If occult blood or GI bleeding are present malignancy will be considered depending on the presentation.  Patient may have a palpable mass, significant weight loss, or no pain with bleeding. Peptic ulcer disease according to Mayo Clinic, are open sores that develop on the inside lining of the upper portion of the small intestine. The most common symptom of a peptic ulcer is stomach pain. Plan: Gastrointestinal Hemorrhage, Unspecified: OMEPRAZOLE 40 MG delayed-release capsule QD. Awaiting capsule endoscopy. Discontinue aspirin capsule QWK Essential (primary) Hypertension: Continue with same medications. Importance of tight control and being compliant with medicines explained.  Decrease sodium intake. Malignant Neoplasm of Prostate: Continue with lifestyle modifications. Counseling is done in detail. Dont wait until the last minute. Provide your requirements and let our native nursing writers deliver your assignments ASAP. Start My Order Referrals: Continue follow up with GI, Urologist, Oncologist Follow up: Follow up office visit in 2 week(s) for lab results If bleeding worsen go to ER