- Please fallow instruction. I need you to make up a soap note for 11 years female patient diagnose with constipation. APA style.
Please and fill out the template completely using your own words for the assessment finding.Fallow the format of the Sample Soap Note and a blank template, which I sent to you as an attachment. I included the empty soap note template you must plug the information in it. I need you to provide the following: APA format with at least with 5 references no older than 5 years old.
Chief patient compliant
The Diagnosis Constipation: ICD 10 code
PMH
PSH
FH
ROS completed. Provide complete and concise summary of pertinent information.
3 differential diagnoses with ICD 10 code describe and discuss why chos
3 Complete vital sign, BMI
Subjective Information
Complete Objective Information
Lab Tests
Allergies
Complete physical exam with critical elements related to subjective data.
Perform Assessment
Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
Create a Plan
Self-Assessment & Clinical Guidelines
Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
B) Discuss Constipation
Expert Solution Preview
Introduction: This SOAP note is for an 11-year-old female patient who has been diagnosed with constipation. The purpose of this note is to document the patient’s information, including subjective and objective data, assessment, diagnosis, and plan of care. The note will follow the SOAP format, which stands for subjective, objective, assessment, and plan.
Chief Patient Complaint: The patient complains of difficulty and infrequency in passing stools, which has been present for two weeks.
Diagnosis: The patient has been diagnosed with constipation, which is coded as K59.0 according to the ICD-10 code.
PMH: The patient has no significant past medical history.
PSH: The patient has no significant past surgical history.
FH: The patient has no significant family history of related conditions.
ROS: The patient reports occasional abdominal pain, bloating, and nausea, but no other significant symptoms.
Differential Diagnoses:
1. Irritable bowel syndrome, coded as K58.0, considering the patient’s chronic symptoms of abdominal pain and bloating.
2. Hypothyroidism, coded as E03.9, as thyroid disorders can cause constipation in some cases.
3. Intestinal obstruction, coded as K56.7, as this condition can also cause infrequent bowel movements.
Vital Signs and BMI:
– Blood pressure: 110/70 mm Hg
– Heart rate: 80 beats per minute
– Respiratory rate: 16 breaths per minute
– Temperature: 98.6°F
– BMI: 20.3 kg/m²
Subjective Information:
The patient reports difficulty passing stools, associated with occasional abdominal pain, bloating, and nausea. The patient also mentions recent changes in her diet and physical activity level, as she has been consuming less fiber and water and engaging in less physical activity.
Objective Information:
– Abdominal exam reveals mild distension and tenderness in the lower quadrant.
– Digital rectal exam indicates a hard stool present in the rectum.
– The rest of the physical exam is unremarkable.
Lab Tests:
– Stool test for occult blood: negative
– Complete blood count: within normal limits
– Thyroid function test: within normal limits
Allergies: The patient has no known allergies.
Assessment:
Based on the patient’s subjective and objective data, the three differential diagnoses were considered. However, the most likely diagnosis is constipation, supported by the hard stool in the rectum, abdominal distension, tenderness, and infrequent bowel movements.
Plan:
1. Increasing fiber and water intake in the patient’s diet.
2. Encouraging physical activity, such as walking or light exercise, to help stimulate bowel movements.
3. Prescribing over-the-counter laxatives, such as magnesium citrate or senna, to help soften the stool and relieve constipation.
4. Follow up with the patient after one week to assess the effectiveness of the treatment plan.
Self-Assessment and Clinical Guidelines:
The S + O data are relevant and support the diagnosis of constipation. The treatment plan is evidence-based and follows the clinical guidelines for managing constipation in pediatric patients. The plan will be compared to the patient’s response, and adjustments will be made accordingly.
B) Discuss Constipation:
Constipation is a common gastrointestinal problem that affects individuals of all ages. It is characterized by infrequent and difficult bowel movements, which can be caused by various factors, including low fiber intake, dehydration, sedentary lifestyle, medications, and certain medical conditions. Constipation can lead to discomfort, abdominal pain, bloating, and complications such as hemorrhoids and fecal impaction. The treatment plan for constipation includes lifestyle modifications, such as increasing fiber and water intake and engaging in physical activity, and medications like laxatives to relieve symptoms. However, it is important to identify and manage underlying causes, such as thyroid disorders or neurological conditions, to prevent recurrence.
