Episodic/Focused SOAP Note
Patients Information
Name: David C. Crawford
Age: 64
Sex: Male
Race: Hispanic White
Chief Complaint. Abdominal Cramps and bloody diarrhea
Subjective: History of the Current Condition
The patient is a Hispanic American aged 64 who presented to the hospital after being referred from a private clinic within the district. The patient reported having started experience unusual symptoms two months and a half ago. Signs started with abdominal pains, followed by an urgency to defecate soon after having a meal. However, the symptoms showed no signs of disappearing, and the urgency to defecate started increasing exponentially. In approximately 46 hours, he was persistently passing stool that is watery mixed with mucous and blood. He also reported an inability to pass the stool despite the urgency. This sign persisted for some hours and kept recurring. He decided to visit a clinic nearby and was treated for gastritis and was prescribed some painkillers ease the abdominal cramps. The symptoms disappeared apart from less severe and irregular abdominal pain. However, after a week, he collapsed at his workplace and was rushed to the hospital by his employee and was discharged days later without a diagnosis. One month ago, Crawford started experiencing the initial symptoms after having a meal or a drink. These symptoms persisted for approximately one week, and were re-admitted in the same hospital where he was rehydrated and further assessment with no conclusive diagnosis.
At the moment, he has developed sores in the lining of the mouth, and the symptoms have worsened, making him pass up to 20 watery stool within 24 hours. The patient has also developed pain on his back and joints, which is acute in the morning or after lifting heavy tools at his workplace. The stool has mucous and mixed with blood, and the patient reports to have lost weight since diarrhea started. He complains of lack and loss of appetite for meals, a general feeling of illnesses, and body weakness. The patient has no surgical history and no significant history of ailments apart from short-sightedness (myopia), which was corrected using a pair of spectacles prescribed to him by his physician. The mother died at the age of 80 years after battling colon cancer.
Objective: Observation made after physical assessment
Generally, he looked weak with unhealthy paleness and could occasionally bend while pressing his abdominal area, probably to ease the discomfort. During the cross-examination, he visited the hospital toilet four times and reported the presence of bloody stool.
I could feel a slight rise in temperature through palpation, which could be 39 degrees, and tenderness in around the abdominal area. The rate of the heartbeat was high and irregular, probably beating at 80 beats per minute. The pulse rate was also very high, indicating hypertension. Besides, a close examination of the eyes showed swollen iris. When I asked him for any pain, he said he has been experiencing irregular sharp painful waves, which he linked to his myopia condition. A tenderness was felt on his knee joints and finger joints, which he said get stiffer in the morning or after walking for long. Finally, I examined his mouth and noticed oral alterations.
Assessment: Differential Diagnosis and Primary Diagnosis
Colorectal cancer, Crohn’s disease, and Colon Polyps
The primary diagnosis was Ulcerative Colitis.
This is because Ulcerative Colitis is chronic conditions linked to diffuse swelling of the colon, which increases morbidity rate and recurring signs of tenesmus, rectal urgency, and intermittent body diarrhea (Rintala et al., 2016). Commencement signs occur from 15 to 40 years. The second peak incident occurs between the ages of 50 and 80 years. Both females and males have equal chances of developing this condition. According to Langan et al. (2007), apart from the manifestation in the bowels, another manifestation like arthritis occurs to 5 percent of the patients with Ulcerative Colitis like in Crawford’s case. Risk factors include family history, and from the case, the mother probably developed Ulcerative Colitis that developed into colon cancer. Some elderly patients show 10 percent oral ulcerations like; in this case, there were sores in the mouth (Zhang et al., 2015). All this proved the highest probability for Ulcerative Colitis.
Plan: Plan for diagnostics and primary diagnosis
Stool Culture. To single out the possibility of bacterial infection, I advocated for stool culture. This procedure involves collecting a small sample of stool and sending it to the laboratory for analysis (Rintala et al., 2016). After 2-3 days, positive results show abnormal bacteria that affect the digestive tract causing diarrhoea.in this case, the stool culture test was negative.
Barium test. This test is conducted to test the rate of digestion. A patient is given food containing barium, a liquid that coats the inside of organs to make them visible on x-ray. This allows the physician to watch as food gets digested in the stomach (Zhang et al., 2015). This test showed a reduced rate of digestion followed by bloody stool.
Primary Diagnosis
Colonoscopy was the best assurance to confirm my diagnosis and rule out other conditions that manifest similarly as Ulcerative Colitis (UC). This test involved inserting a long specialized tube into his rectum (Harbord et al., 2017). A small video camera at the tip assisted in viewing the inside of the colon in real-time. Inflammation and sores along the small and large intestines were identified.
Treatment/alternative therapies
Treatment involves treating signs of inflammation and reducing the occurrence of signs. The first-line medical treatment involves 5-aminosalicylic acid (Harbord et al., 2017). This reduces the causes of inflammation. Since the patients incurred pain during the barium test, I advocated for Prednisone in the dosage of 50 mg in a day.
The alternative medication will be an intravenous injection of corticosteroids, such as 40 mg of Solu-Medrol, if Crawford doesn’t respond to the primary medication (Bressler et al., 2015). Nonpharmacologic treatment may be adopted due to a lack of efficiency with current treatment. Lactobacillus is effective and works synonymously with 5-aminosalicylic acid (Hindryckx et al., 2016). Together with the use of Escherichia coli as an alternative remedy, they can effectively reduce UC and recurring chances. The patient is advised to periodically visit the hospital to assess the disappearance or recurrence of Ulcerative Colitis.
Reflection Notes
The problem in this situation was subjecting the patient to an array of tests before confirming the presence of Ulcerative colitis. Furthermore, the patient was exposed to a test that could have otherwise worsened his condition due to mouth ulcerations.in the case of a similar patient, I would directly advocate for a colonoscopy, which would directly confirm UC, among other illnesses.