Abdominal SOAP Note Example

Below is a nursing SOAP note for an abdominal examination based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

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• HEENT SOAP Note Example
• Respiratory SOAP Note Example
• Cardiovascular SOAP Note Example
• Musculoskeletal SOAP Note Example
• Neurological SOAP Note Example
• Skin, Hair, and Nails SOAP Note Example
• Discharge SOAP Note Example

Subjective:

1. Chief Complaint: Patient reports abdominal pain and bloating.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started gradually about two weeks ago.
   • Location: The patient reports experiencing the abdominal pain in the lower abdomen, mainly on the left side.
   • Duration: The patient mentions that the symptoms have been intermittent, occurring multiple times throughout the day.
   • Character: The patient describes the abdominal pain as a dull, crampy sensation. They report feeling bloated and notice changes in their bowel movements, including alternating constipation and diarrhea.
   • Aggravating Factors: The patient reports that the symptoms worsen after meals and during times of stress.
   • Relieving Factors: The patient states that resting, applying a heating pad, and taking over-the-counter antacids provide temporary relief.
   • Treatment/Interventions Tried: The patient has been avoiding triggering foods and taking over-the-counter antidiarrheal medication for symptom management.
3. Past Medical History: Document any relevant past medical conditions, surgical procedures, or chronic gastrointestinal disorders that may be related to the current symptoms. Include details about any previous episodes of abdominal pain or gastrointestinal diagnoses.
4. Allergy History: Inquire about any known allergies to medications or specific foods that may cause gastrointestinal symptoms. Note the type of reaction experienced and any known allergens to avoid.
5. Medication History: Record the patient’s current and past medication history, including prescribed medications, over-the-counter remedies, or dietary supplements taken for gastrointestinal symptoms.
6. Social History: Explore the patient’s dietary habits, including specific food triggers, alcohol consumption, and any recent changes in diet. Assess any occupational or environmental exposures that may contribute to gastrointestinal symptoms.
7. Review of Systems: Conduct a brief review of systems, focusing on symptoms related to the gastrointestinal system. Inquire about associated symptoms such as nausea, vomiting, changes in appetite, weight loss, or blood in the stool.

Objective:

1. Vital Signs: Blood pressure: 120/80 mmHg, Heart rate: 78 bpm, Respiratory rate: 16 breaths per minute, Temperature: 36.9°C.
2. General Appearance: The patient appears comfortable, with no signs of distress or acute illness.
3. Abdominal Examination: Soft and non-tender abdomen, no palpable masses or organomegaly, normal bowel sounds auscultated in all quadrants.

Assessment:

1. Medical Diagnosis: Irritable bowel syndrome (IBS).
2. Problem Identification: Patient reports abdominal pain, bloating, and changes in bowel habits.
3. Relevant Findings and Abnormalities: Presence of intermittent lower abdominal pain, bloating, and alternating constipation and diarrhea.
4. Client Education Needs: Patient requires education on managing IBS symptoms, dietary modifications, stress reduction techniques, and the importance of regular follow-up appointments.

Plan:

1. Medical Interventions:
   • Recommend dietary modifications, such as a high-fiber diet and avoiding trigger foods.
   • Prescribe medications for symptom relief, such as antispasmodics or laxatives, if necessary.
   • Discuss the use of stress reduction techniques, such as relaxation exercises or cognitive-behavioral therapy.
2. Patient Education:
   • Educate the patient about IBS triggers and the importance of maintaining a symptom diary to identify individual triggers.
   • Provide dietary guidance and resources on low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diets if appropriate.
   • Discuss the importance of regular exercise, adequate hydration, and the benefits of stress management techniques.
3. Referrals or Consultations:
   • Refer the patient to a registered dietitian for personalized dietary counseling.
   • Consider a referral to a gastroenterologist for further evaluation or specialized treatment options.
4. Safety Measures:
   • Assess the patient’s overall well-being and mental health status, offering appropriate resources or referrals if needed.
   • Educate the patient on when to seek immediate medical attention for severe abdominal pain or any alarming symptoms.
5. Evaluation:
   • Schedule a follow-up appointment in one month to assess symptom improvement and adjust the treatment plan if needed.
   • Monitor for any signs of worsening symptoms or new gastrointestinal complications.

• This example demonstrates an abdominal SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes vital signs and examination findings related to the abdominal region.
• The assessment section includes the medical diagnosis, relevant findings, and problem identification. The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.