Crohn’s Disease Evidence-Based Clinical Intervention SOAP note format essay
Your Evidence-Based Clinical Intervention should be submitted in a Microsoft Word document following APA style and should include the following:
**** CROHN’S DISEASE
The medical problem/diagnosis/disease.
Typical presenting signs and symptoms including:
Onset, Characteristics, Location, Radiation, Timing, Setting, Aggravating factors, Alleviating factors, Associated symptoms, Course since onset, Usual age group affected
Concomitant disease states associated with the diagnosis
The pathophysiology of the problem.
Three differential diagnoses and the usual presenting signs and symptoms in priority sequence with rationales.
Reference to at least two current journal articles that show evidence-based practice as how to best treat this disorder related to the primary differential.
The expected outcomes of the intervention.
Algorithms if available.
A typical clinical note in SOAP format.
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Subjective Data
Chief complain- abdominal pain
History of Presenting Illness-C.K is a 40-year-old African American with Crohn’s disease. She presented to the emergency department with complaints of severe abdominal pains for two days, diarrhea, vomiting and nausea. The abdominal pain was of sudden in onset, sharp in nature and radiated to all parts of the abdomen. On a scale of 0-10, she rated the pain 5/10. Crohn’s Disease Evidence-Based Clinical Intervention SOAP note format essay. The pain was accompanied with three episodes of diarrhea, nausea and four episodes of vomiting. C.K reported that for the fear of vomiting and diarrhea, she did not eat anything but only drank several glasses of water. The following day, the pain worsened to 9/10 and thus decided to come to the ER.
Medications- mesalamine 500 mg QID and omacor 900 mg QID
Allergies-None
Past Medical History- Diagnosed with Crohn’s disease in 2013
Past Surgical History-none
Personal Socio-economic History-Married lives with the husband her two children aged 11 and 14. All are in good health. Is a smoker for 30+pack years but does not take alcohol. She denied the use of any other illicit drugs and substances. Her diet generally comprises of small food carbohydrates and proteins but admits to not observing a healthy diet.
Immunization History-UpToDate
Family History- mother is deceased died due to complications from hypertension and type 2 Diabetes Mellitus. Has two sisters, one was diagnosed with hypertension. Father is alive and was diagnosed with schizophrenia. The paternal grandmother died of leukemia.
Review of Systems
GIT-denies jaundice, weight loss, anorexia, has nausea, vomiting, diarrhea, and abdominal pain
CNS-denies dizziness, vertigo, seizures, tremors and paresthesia
Respiratory-denies wheezing and cough
Crohn’s Disease Evidence-Based Clinical Intervention SOAP note format essay
CVS-denies chest pains, dyspnea, syncope, palpitations, edema, and PND
HEENT-denies loss of vision, blurred vision, diplopia, eye pain, eye discharge, ear discharge, ear pain, nosebleeds, dysphagia, voice hoarseness, and nasal discharge
Musculoskeletal-denies limb or joint pains, joint swelling, stiffness and muscle weakness
Immunologic-denies exposure to HIV, urticarial and persistent infections
Endocrine-denies heat and cold intolerance, polyuria, polydipsia, and polyphagia
Psychiatric-denies anxiety, depression, suicidal ideation, mental disturbance, paranoia, and hallucinations
Objective Data
General Exam-middle-aged lady who is obese, alert and oriented in time, place and person
Vital Signs-pulse rate 80bpm, temp-36.50c, respiratory rate-16cycles/min, O2 Sat-97% on the RA, BP-120/81mmHg, pain score-9/10
Systemic Exam
GIT-abdomen is soft, non-tender and not distended, no palpable masses has hyperactive bowel sounds on auscultation, has RUQ tenderness on palpation, no splenomegaly
CVS-normal S1 and S2, no murmur or gallop rhythm, no palpitation, no edema, JV not distended.
Rectal-no sores or lesions, guaiac positive stool on examining finger
HEENT-normal conjunctiva, PEBRL, no exudates or hemorrhage, has a normal visual acuity, the ears are normal with no deformities, canals bilaterally clear, intact tympanic membranes, ho hearing loss, no fluid, normal septum and nasal mucosa, no nasal discharge, normal tongue, no exudates or erythema on posterior pharynx, no masses on the neck, midline trachea, no enlargement.
Respiratory-lungs bilaterally clear on auscultation, normal respiratory effort
Skin-no lesions, indurations or subcutaneous nodules
CNS-oriented in time, place and person, memory intact, cranial nerves 11-XII intact, normal reflexes
Musculoskeletal-deferred gait and posture due to pain, no bone or joint deformities, normal ROM and strength of all joints, no joint tenderness
Assessment
Laboratory Diagnostic Tests:
Blood Chemistry
Na-136
K-2.9
Cl-103
C02-26
BUN-9
Cr-0.7
Gluc-90
Ca-9.7
Mg-1.3
PO4-2.2
Complete Blood Count
WBC-4.4
Hb- 10.8
Hct-32.8
Plts-311
Total Bili-0.2
AST-13
ALT-22
Alk Phos-87
GGT-52
Lipase-13
ESR-30mm/hr
Radiologic Tests
Abdominal X-ray-there was several dilated loops of the small bowel with levels of distal gas and air-fluids. This potentially indicates thickening of the walls of the colon to suggest active colitis in a patient diagnosed with Crohn’s disease. There was no central effusion
CT scan of the Abdomen-there was thickening of the mucosa; terminal ileum was consistent with active Crohn’s disease, no fistulas, no bowel obstruction, no abscesses. Crohn’s Disease Evidence-Based Clinical Intervention SOAP note format essay.
Differential Diagnoses
Exacerbation of Crohn’s Disease-C.K presented with diffuse abdominal pain of sudden onset, accompanied by the symptoms of nausea, diarrhea, and vomiting. High chances are that the chronic pain is from Crohn’s disease exacerbation since the use of prednisolone has helped to resolve her history, symptoms, laboratory and radiologic findings (Kalla et al., 2014). Crohn’s disease has an unknown etiology and can affect any part of the GI tract. Although patients can at times be asymptomatic, in case of exacerbations, patients present with the complaints of abdominal pain, nausea, diarrhea, fever and possible weight loss. The patient’s abdominal imaging also detected an active form of the disease thus the most likely diagnosis.
Obstruction of the Small Bowel-is also a potential differential since it happens following blockage of the GI contents. A patient presents with complaints of constipation, abdominal pain, reduced appetite, vomiting and nausea following distension of the abdomen and fullness (Paulson & Thompson, 2015). On the contrary, C.K was able to pass stool in this case and never experienced any form of abdominal distension or constipation. Besides, the likelihood of obstruction of the small bowel to present with guaiac positive stool on examining finger is very minimal. Although the small bowel had dilated loops as revealed by the abdominal x-ray which also occurs in obstruction of the small bowel, the abdominal CT scan was clear that this was thickening of the ileum mucosa, highly suggestive of Crohn’s disease.
Acute Ischemia of the Mesenteric-ischemia of the mesenteric artery happens when there is reduced blood flow following a vasospasm or occlusion that causes hypoperfusion. Patients usually present with severe abdominal pain of rapid onset that is localized in the peri-umbilical region, vomiting, and nausea (Clair & Beach, 2016). Its risk factors include a hypercoagulability state or obstruction of the small bowel. However, C.K is less likely to have acute mesenteric ischemia since her vital signs were within normal range and her abdominal pain was of sudden onset and localized in the RUQ. Crohn’s Disease Evidence-Based Clinical Intervention SOAP note format essay.
Plan
Immediate Intervention- Starting IV fluids: phenegram12.5mg with 10mls Normal Saline, fentanyl 40mcg to prevent nausea, vomiting, and rehydration (Torres et al., 2017).
Pharmacotherapy- prednisone 60mg for two weeks, the patient will be required to slowly taper the dosage by 10mg every two weeks. The patient will, however, continue with her omega-3 supplements and other drugs for Crohn’s disease (Lichtenstein et al., 2018).
Health Promotion and Disease Prevention-The patient will have to observe a specific diet to prevent exacerbations and help in symptoms alleviation. In this case, the most recommended dietary changes include: avoiding carbonated drinks and foods rich in fiber. Crohn’s Disease Evidence-Based Clinical Intervention SOAP note format essay.
References
Clair, D. G., & Beach, J. M. (2016). Mesenteric ischemia. New England Journal of Medicine, 374(10), 959-968.
Kalla, R., Ventham, N. T., Satsangi, J., & Arnott, I. D. (2014). Crohn’s disease. Bmj, 349, g6670.
Lichtenstein, G. R., Loftus, E. V., Isaacs, K. L., Regueiro, M. D., Gerson, L. B., & Sands, B. E. (2018). ACG clinical guideline: management of Crohn’s disease in adults. American Journal of Gastroenterology, 113(4), 481-517.
Paulson, E. K., & Thompson, W. M. (2015). Review of small-bowel obstruction: the diagnosis and when to worry. Radiology, 275(2), 332-342.
Torres, J., Mehandru, S., Colombel, J. F., & Peyrin-Biroulet, L. (2017). Crohn’s disease. The Lancet, 389(10080), 1741-1755. Crohn’s Disease Evidence-Based Clinical Intervention SOAP note format essay