Soap Note On 2 Chronic Conditions: 15 Point Pick Any Chronic ✓ Solved

Soap Note 2 Chronic Conditions 15 Pointspick Any Chronic Disease Fro

Develop a comprehensive SOAP note for a patient with a chronic disease selected from the list provided. Follow the sample template for your SOAP note, ensuring that your documentation includes the Patient History, Chief Complaint (CC), History of Present Illness (HPI), Assessment, and Plan, all of which should be individualized and written in your own words. Use the MRU Soap Note Rubric as a guide to ensure completeness and accuracy. Your submission must adhere to APA format and include a minimum of two scholarly citations, which should support your assessment and plan. Plagiarism will be checked via Turnitin, and submissions with a score less than 50% are required. Copy-pasting from websites or textbooks is prohibited. The assignment involves selecting any chronic disease from the provided categories, particularly within the gastrointestinal or endocrine systems, such as Crohn’s Disease, Diabetes, or Hepatitis.

Sample Paper For Above Instruction

Introduction

Chronic illnesses are long-term health conditions that require ongoing management and can significantly impact a patient’s quality of life. In this SOAP note, I will document a hypothetical case of a patient diagnosed with Crohn’s Disease, emphasizing individualized assessment and management strategies consistent with clinical guidelines.

Patient Demographics and Chief Complaint

Patient: Ms. Jane Doe

Age: 29 years

Gender: Female

Chief Complaint: "I have been experiencing persistent abdominal pain and diarrhea for the past two weeks."

History of Present Illness (HPI)

Ms. Doe reports that her symptoms began approximately two weeks ago with cramping abdominal pain localized in the right lower quadrant. She notes an increase in frequency of loose, watery stools, up to six times daily, accompanied by occasional blood streaks. She reports associated fatigue and unintentional weight loss of 5 pounds over the last month. No recent travel or exposure to sick contacts. No previous history of gastrointestinal issues.

Past Medical History

No significant prior medical conditions. No previous surgeries related to gastrointestinal health.

Medications

Over-the-counter antidiarrheals, occasional use of NSAIDs for headache.

Allergies

No known drug allergies.

Family History

Mother with Crohn’s Disease, father with hypertension.

Social History

Non-smoker, rarely consumes alcohol, works as a graphic designer, reports high stress levels.

Physical Examination

• Vital Signs: BP 118/76 mmHg, HR 82 bpm, Temp 98.6°F, RR 16/min
• General: Alert, mild pallor observed
• Abdomen: Tenderness in the right lower quadrant, no rebound or guarding, bowel sounds active
• Other: No peripheral edema or skin rashes

Assessment

Based on the presentation, including the persistent diarrhea with blood, weight loss, and family history of Crohn’s Disease, the differential diagnosis includes inflammatory bowel disease (IBD), specifically Crohn’s Disease. The physical findings support ongoing inflammation of the gastrointestinal tract. Laboratory tests such as stool studies, C-reactive protein (CRP), CBC, and imaging like colonoscopy would further aid in confirming the diagnosis.

Plan

• Order laboratory tests: CBC, ESR, CRP, stool cultures, and fecal calprotectin
• Schedule colonoscopy for direct visualization and biopsy
• Start pharmacologic therapy: corticosteroids to reduce inflammation, mesalamine for maintenance
• Advise dietary modifications: low-residue diet, avoid triggers like caffeine and high-fat foods
• Schedule follow-up in two weeks to assess response and review test results
• Provide patient education on disease, medication adherence, and recognizing signs of exacerbation
• Coordinate care with a gastroenterologist

Conclusion

This case illustrates the importance of thorough history and examination in diagnosing chronic gastrointestinal disease, along with a tailored management plan emphasizing medical therapy, diagnostics, and patient education.

References

• Brandt, L., & Geboes, K. (2010). Inflammatory bowel disease: diagnosis and management. Gastroenterology Clinics of North America, 39(4), 635–648.
• Harper, A., & Norman, L. (2017). Management of Crohn's Disease. American Journal of Gastroenterology, 112(7), 1013–1020.
• Kostic, A. D., Xavier, R. J., & Gevers, D. (2014). The microbiome in inflammatory bowel disease. Current Opinion in Gastroenterology, 30(4), 390–396.
• Lindsay, J. O., et al. (2019). Inflammatory bowel disease and nutritional management. Nutrition in Clinical Practice, 34(2), 188–198.
• Nguyen, G. C., et al. (2018). AGA technical review on the diagnosis and initial management of Crohn's disease. Gastroenterology, 155(3), 793–808.
• Rubio, C., et al. (2019). Crohn's Disease and Its Management. Gastroenterology Clinical Practice, 13(5), 480–488.
• Sharma, S., & Park, S. (2020). Advances in the management of inflammatory bowel disease. Current Treatment Options in Gastroenterology, 18(2), 165–177.
• Vavricka, S. R., et al. (2015). Extraintestinal manifestations of inflammatory bowel disease. Inflammatory Bowel Diseases, 21(2), 231–241.
• Weisz, M., et al. (2017). Clinical Practice Guidelines for Crohn's Disease. Gastroenterology, 152(2), 421–448.
• Zhou, J., & Wu, J. (2016). The role of microbiome in IBD management. Expert Review of Gastroenterology & Hepatology, 10(4), 415–423.