Nursing  SOAP

ABDOMINAL ASSESSMENTSubjective:CC: “My stomach hurts, I have diarrhea and nothing seems to help.”HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.PMH: HTN, Diabetes, hx of GI bleed 4 years agoMedications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhsAllergies: NKDAFH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERDSocial: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)Objective:VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbsHeart: RRR, no murmursLungs: CTA, chest wall symmetricalSkin: Intact without lesions, no urticariaAbd: soft, hyperactive bowel sounds, pos pain in the LLQDiagnostics: NoneAssessment:Left lower quadrant painGastroenteritis

 
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