MSN 572 Week 3 Assignment-Immersion Documentation and SOAP Note

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Ali Junayed

United States University

MSN 572

Prof. Victoria Kaminski

November 2023

Immersion Documentation and SOAP Note

Initials: RF

Date: 11/8/2023

Age: 49

Sex: Male

CC: Abdominal discomfort and pain in the right upper quadrant.

HPI: RF, a 49-year-old male, came in for a problem visit, citing pain in his right upper quadrant and abdomen. RF said he was experiencing pain and discomfort in his upper right abdomen. He has been experiencing a dull discomfort for the previous two weeks. The pain has been building up over time and shows no signs of stopping. He has noted the pain is more noticeable after meals and seems to radiate towards the back. RF also indicated that he sometimes experiences bloating, but there has been no alteration to his bowel routine. There was no record of any recent injuries or trauma. Neither fever nor chills nor jaundice accompany the pain.

Social History:

RF is a married 49-year-old man who works as a computer programmer. He claims he doesn’t do drugs or drink. Regular exercise and a healthy diet help him stay in shape.

Medical History:

RF does not have any significant medical, surgical, or allergy history.

Family History:

There is no history of serious illness or gastrointestinal problems in RF’s family.

ROS

Cardiovascular: Heart and blood vessel conditions are normal.

Musculoskeletal: No joint pain or muscle weakness.

Respiratory: No respiratory symptoms such as wheezing, wheezing, or shortness of breath.

Gastrointestinal: No nausea or vomiting.

Genitourinary: No urine symptoms; genitourinary system.

Neurological: No abnormalities.

Integumentary: There are no sores or other blemishes on the skin.

Psychiatric: No alterations in mental state or disruptions in sleep patterns. 

Physical Exam

Inspection: The patient’s abdomen is smooth and free of obvious scars or herniations, per a physical examination. There was no sign of jaundice. The skin looks fine.

Auscultation: All four quadrants of the body have normal bowel sounds when auscultated.

Palpation: Light and deep palpation in all four quadrants of the body reveal no soreness or pain. Nothing of mass was detected. Within 7–8 cm from the top right quadrant, you can feel the liver’s border. It is impossible to feel the spleen.

Specialized Tests: The results of the specialized tests were negative for costovertebral angle (CVA) soreness, Murphy’s sign, Rovsing’s sign, and ascites (fluid wave test).

Diagnostic Plan

1. Tests of liver and gallbladder function, in addition to a complete blood count (CBC), are used to diagnose liver and gallbladder involvement.
2. Ultrasound of the abdomen to check for gallstones and inflammation in the gallbladder (Mayo Clinic, 2018).
3. If preliminary diagnostics suggest a CT scan of the abdomen, have one done.

Therapeutic Plan

1. Treatment of abdominal pain symptoms when they arise with over-the-counter pain relievers.
2. Adjustments to the diet in order to track symptoms after eating (Weiss, 2023).
3. In one week, we’ll reassess your symptoms and look over your test results.

Education

The significance of regular checkups and other diagnostic procedures will be stressed to the patient. Also, it should be explained how alterations to one’s diet may help relieve symptoms.

Follow Up

The patient was urged to get emergency medical help before his next consultation if he experienced severe abdominal discomfort, worsening symptoms, fever, or jaundice.

References for MSN 572 Week 3

Mayo Clinic. (2018). Abdominal Ultrasound – Mayo Clinic. Mayoclinic.org. https://www.mayoclinic.org/tests-procedures/abdominal-ultrasound/about/pac-20392738

Weiss, C. (2023, September 12). Mayo Clinic Q and A: Food to Reduce Bloating. Mayo Clinic news network. https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-food-to-reduce-bloating/#:~:text=Eat%20smaller%20meals%2C%20more%20frequently

Finally MSN 572 Week 3 is about creating a clinical SOAP note for patient assessment, following a patient case from history to diagnostic plan.

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