Description
Respond at least two times each to both of your colleagues who presented this week. The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to one of the three discussion prompts that your colleague provided in his or her video/SOAP note presentation. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
Focused SOAP Note Template
Patient Information:
MV, 62, M, Caucasian
S.
CC (chief complaint):
Nausea and vomiting
HPI:
Mr. MB, it’s a 65-year-old Caucasian male who presented to an outside facility after being found down in his home by his sister. Per the sister, the patient was found in the restroom covered in emesis and stool. The patient was too weak to get himself up from the floor and therefore was brought into the hospital by his sister. At the outside facility, he was found to be borderline hypotensive with an elevated lactic acid. He was transferred to our facility for further treatment. Mr. MB had been discharged from our facility on 12/23 pending the start of his treatment for his newly diagnosed pancreatic cancer.
Current Medications:
Carvedilol 12.5 mg tablet by mouth BID
Fentanyl 12 mcg/hr One patch every 72 hours
Hydromorphone 2 mg tablet Q4H PRN for moderate or severe pain
Lantus 10 units daily
metformin 100 mg tablet by mouth BID
Omega three fatty acid fish oil by mouth daily
Zofran 4 mg tablet by mouthQ8H PRN for nausea and vomiting
Miralax 17g by mouth daily
Pravastatin 20 mg tablet by mouth daily
Zoloft 50 mg tablet by mouth at bedtime
Spironolactone 25 mg tablet by mouth twice a week Monday and Friday
Flomax 0.4 mg tablet by mouth daily
vitamin B-1 100 mg tablet by mouth daily
Allergies:
Allergic to morphine causing itching.
PMHx:
Pancreatic cancer
Liver metastasis
Diabetes type 2
Hypertension
Benign prostatic hyperplasia
Soc and Substance Hx:
Patient lives out of town is currently in town for treatment. He lived on his own until recently he moved in with his sister. Patient denies any history of smoking or tobacco use. He reported history of heavy drinking. He is Catholic and emphasizes faith as an important part of his life.
Fam Hx:
Patient reports having one living sister. No other history with regard to family was given.
Surgical Hx:
No past surgical history.
Mental Hx:
Mental health is unable to be assessed at this time.
Violence Hx:
There is a concern for safety as the patient was found down and too weak to be able to get up on his own prior to this admission.
Reproductive Hx:
Patient is single with no children.
ROS:
GENERAL: The patient has had recent weight loss chills weakness and fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: The patient has had nausea vomiting and diarrhea. Also positive for abdominal pain secondary to ascites.
GENITOURINARY: Recent change in the flow of urine.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
The patient has been positive for dizziness and recent inability to control bowel movements.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: Hematemesis reported.
LYMPHATICS: Positive for enlarged lymph nodes.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance.
ALLERGIES: Only allergic to morphine no report of seasonal allergies.
O.
Physical exam:
VS: T: 36.3, HR: 91, RR: 19, SPO2: 96% (NC 2L), BP: 80/56,
GENERAL: the patient is lethargic pale and weak very hard to arouse.
HEENT: Normocephalic, not JVD, symmetrical with no facial drooping. The sclera is white pupils are equal and reactive.
CARDIOVASCULAR: S1 and S2 noted with no abnormal heart sounds.
RESPIRATORY: Pulmonary efforts are normal with patient on 2 liters nasal cannula. Breath sounds are diminished.
GASTROINTESTINAL: Abdomen is distended within IP drain to the right upper quadrant. Dressing is dry and intact. Bowel sounds are present in all four quadrants.
GENITOURINARY: Patient has a Foley catheter in place.
NEUROLOGICAL: Patient is lethargic hard to arouse and unable to hold a conversation.
Diagnostic results:
CBC
Urinalysis
BMP
Liver panel
Chest x-ray
KUB
Lactic acid
C-Diff
ABG
Blood cultures
EGD
A.
Differential Diagnoses:
Pancreatic cancer
Sepsis
GI bleed
Anemia
P.
Treatment naïve further education is needed. The patient needs to be stabilized and recover from acute problems before being considered for chemotherapy.
Fluid resuscitation as needed to minimize vasopressor use.
Monitor pan cultures. Broad spectrum antibiotics.
Trend lactate level.
GI bleed prophylaxis. EGD
Monitor ABGs and glucose level.
Also included in this section is the reflection.
The patient presented to the hospital after being found down by his sister. The patient had been having nausea and diarrhea for a couple of days with possible hematemesis. When evaluated and the emergency center he was found to have an elevated lactic acid and was borderline hypotensive. The patient presented with symptoms that were consistent with those for a sepsis diagnosis which include hypotension, nausea, vomiting, weakness, fatigue, fever, and chills (Evans, 2020). With the patient also having an elevated lactic acid the patient would be treated as a septic patient. Another one of the differential diagnoses that could fit the patient’s presentation is that of a GI bleed. The patient has been throwing up for a couple of days. However, it is important to note that on the emesis there was a mention of possible blood. With the patient having a newly diagnosed pancreatic cancer the likelihood of an upper GI bleed is likely. Although rare erosion of arteries that supply the pancreas can result in GI bleeds (Nemet, 2022). In the case of Mr. MB, the likelihood of erosion of his arteries is high as he has recently been diagnosed with pancreatic cancer. He was due to follow up as an outpatient for evaluation and treatment options. He was currently being seen by supportive care due to cancer-associated pain. Pancreatic cancer is the 11th most common cancer and is most associated with abdominal pain, lower back pain, jaundice and weight loss which were reported in the patient assessment (Coveler, 2021).
References
Coveler, A. L., Mizrahi, J., Eastman, B., Apisarnthanarax, S. J., Dalal, S., McNearney, T., & Pant, S. (2021). Pancreas Cancer-Associated Pain Management. The Oncologist, 26(6), e971–e982. https://doi.org/10.1002/onco.13796
Evans, M. M. A. (2020). Sepsis. Salem Press Encyclopedia of Health.
Nemet, I., Reyes, H., Basra, D., Coloka-Kump, R., & Cohen, S. (2022). Pancreatic Pseudoaneurysm: A Rare Cause of GI Bleeds. Family Doctor: A Journal of the New York State Academy of Family Physicians, 10(4), 42–43
