According to Ball et al. it is critical to obtain a detailed abstract history of the torment when treating a patient with generalized stomach or abdominal pain in order to narrow the range of possible differential diagnoses. The main complaint should be “stomach or abdominal pain.” More information about the patient’s historical background regarding the current condition (HPI) and overall wellbeing from a previous time is required in the subjection section of the SOAP note in this case, which could be accomplished by asking more engaged or focused questions. More information about the patient’s overall health, eating habits and history prior to this condition is required, which could be obtained by asking more engaged or focus questions. It is also necessary to provide additional information about any changes in appetite and defecation or bowel movement. The historical context of the current illness should include information such as the beginning or onset, duration, qualities or characteristics, intensifying or exacerbating, and mitigating or alleviating symptoms in the case of the abdominal pain. It is critical to retain information on the nature of the pain, such as whether it is transitory or confined, whether the severity is increasing or decreasing, and where it originates and ends. One of the most basic questions to ask before beginning the test is about the location of the pain. The patient should also be asked what he was doing before the pain started. Identifying which parts of the abdomen that the pain is felt most as well as responding to questions posed during the ROS is missing. This information is critical in narrowing down to the absolute most likely diagnose.
Despite the patient’s mention of diarrhea, mote information about bowel and urinary habits should be included. This includes the length and frequency of diarrhea episodes in a day, relieving and aggravating factors, and other diarrhea related symptoms. Incontinence, hesitancy, dysuria, urgency, and increased frequency of urination should all be documented. Still on the subject of urinary habits, details about the odor, color, and discomfort felt after or during a bowel movement should be provided. It is critical to rule out any potential abdominal pain side effects such as nausea and vomiting. Clearly, the patient had a 4year history of GI bleeding. As a result, details such as the absence or presence of blood in the vomitus or stool, as well as color and smell should be included.
Patient reports of missing to take medications would be filed under meds the last time he took them, necessitating a distinction between the justification for each medicine and why it should be discontinued. Also, a differential conclusion thought to be a negative finding for colon malignant growth or cancer should be recorded in the Assessment section. Finally, the family history must return to three generations, of which two out of three is documented. This healthcare provider ROS appears to have been derailed, and he failed to take note of or complete the remainder of the PMHx. Inquiries about lifestyle and exercise for diabetes and hypertension are acceptable practice and require legitimate clinical documentation. CAGE testing can assist you in avoiding alcohol addiction. What exactly is meant by “intermittent or occasional” drinking? How many, how frequently, and what are the ramifications?