Problem
SOAP Note:
Date: 09/21/17
Pt Identity
J.G., 56 y/o male, seems reliable. Prior medical records reviewed.
Chief Concern
"I've had diarrhea for about a week or so."
History of Present Illness
Having 5-10 soft unformed light-brown stools per day (including overnight), which started suddenly 7 days ago. He has not had diarrhea this bad before. Has not identified a relationship between diarrhea and food or fluid intake. Some relief from Imodium and Pepto-Bismol. Also reports 3-day history of increased hemorrhoidal bleeding during defecation w/ perianal burning and itching for about 20 minutes after each BM. Denies direct contact with anyone experiencing similar symptoms, recent travel, and dietary changes. Started taking metformin 500 mg BID 2 weeks ago. Has h/o irritable bowel syndrome, previously well-controlled on Bentyl.
Past Medical History
Adult Illnesses
HTN for "around 15 years" - controlled on lisinopril/HCTZ
Irritable bowel syndrome "since I was a teenager" - Bentyl
T2DM, diagnosed 2 weeks ago - BG stable on metformin
Sinus tachycardia for "about a year" - controlled on metoprolol
Denies CA, CAD, CVA, and HLD.
Health Maintenance
Colonoscopy ordered last year, not done d/t fear of bowel prep causing incontinence.
Vaccines "up to date" per patient. Has not had hepatitis B vaccine.
Childhood Illnesses
IBS, as noted above.
Surgical History
None reported.
Family History
Uncle died age 47, colon cancer. Otherwise noncontributory.
Accidents/Injuries
Denies.
Hospitalizations
Denies.
Psychosocial History
Married, 3 grown children. Works as a high school science teacher w/ intermittently high stress, but has not noticed an increase recently. Denies h/o military service.
Denies smoking, alcohol, and recreational drug use.
Monogamous sexual partner, denies current or prior receptive anal intercourse or rectal-oral sexual practices.
Denies recent domestic or international travel, camping/hiking, and fishing/hunting. Denies owning pets.
Allergies
NKDA. Denies environmental and food allergies.
Current Medications
Lisinopril/HCTZ 20/12.5 daily. Last dose this morning.
Dicyclomine (Bentyl) 40 mg q6h. Last dose this morning.
Metformin 500 mg BID. Last dose this morning.
Metoprolol 50 mg BID. Last dose this morning.
Acetaminophen 1000 mg PRN for "aches and pains". Last dose 2 days ago.
Review of Systems
General: Denies weight change, fever, chills, night sweats, fatigue, weakness, and changes in appetite.
Skin: Denies rashes, ulcerations, dryness, flaking, and excessive sweating.
Pulmonary: Denies cough, dyspnea, increased sputum production, hemoptysis, snoring, and wheezing.
Cardiovascular: Denies chest pain, palpitations, orthopnea, PND, known heart murmurs, edema, intermittent claudication, leg cramps, and varicose veins.
GI: Reports diarrhea, perianal burning and itching, and bright-red blood on toilet paper, as described above. Reports history of hemorrhoids. Denies N/V, indigestion, abdominal pain or cramping, excessive flatulence, bloating, fecal incontinence, constipation, anal trauma, and dark tarry stools. Last BM was 15 minutes before appointment, light brown, soft and unformed.
Psych: Denies feeling depressed, nervous, or anxious.
PHYSICAL EXAM
Constitutional: Appears well-groomed, well-nourished, and well-developed. Sitting comfortably in exam room chair. T 98.1F (oral), HR 114, RR 16, BP 118/99 (right). BMI 28.4.
Skin: Exposed skin is smooth, free of lesions, bruising, tattoos, and piercings.
Lungs/Thorax: Rate regular and unlabored. No accessory muscle use. Lung sounds clear and equal bilat. Resonant in all lung fields. Nail beds pink w/o clubbing.
Cardiovascular: Regular rate/rhythm w/o clicks, gallops, rubs, S3, S4, or murmurs. Pedal pulses 2+ bilat. Skin warm, dry. No edema.
Abdomen: Round, soft, symmetrical, w/o masses, lesions, or hernia. Bowel sounds hyperactive x4 quadrants. Resonant w/ gastric tympany. No tenderness or rigidity on light and deep palpation. No renal/aortic/iliac bruits.
Psych: Affect bright and appropriate.
i. Based on the documented health history, identify 2 "provoking factors" for diarrhea that we can rule out (e.g., sick contacts). Identify 2 "provoking factors" that for diarrhea that should still be considered for J.G.
ii. His medication list is incomplete. Which 2 medications are missing, and what information (besides their names) is important to document about them?
iii. Based on his history and physical exam, create your patient's problem list.you should include at least 5 problems. Remember this should include anything "abnormal" about your patient - not just a list of medical diagnoses.
iv. There is at least 1 system missing from the Physical Exam that is relevant for this acute visit. Which system is missing, and what problem(s) are you specifically looking for?
v. What do you think is causing his acute diarrhea? Explain your answer. Include at least 1 peer-reviewed source.