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SOAP Diarrhea

By Jose Dixon,2014-05-09 22:28
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SOAP Diarrhea

SOAP: Diarrhea

Problem List:

Medication List:

Subjective:

ID

    HPI or chief complaint:

Symptoms:

    ; Onset, duration, frequency, timeline of symptoms

    ; Size of stools, mucus or blood in stool, color

    ; Consistency and number of stools, volume

    ; Odor, greasy, floating ; Previous episodes

    ; Food associations

    ; Fever, abdominal pain, vomiting, weight loss, appetite

    ; Urgency, tenesmus

    ; Incontinence

Past medical history:

    IBS

    Inflammatory bowel disease Antibiotic use

    Spure

    Hepatitis

    Thyroid disease

Medication history

Family history:

    ; Inflammatory bowel disease ; Irritable bowel syndrome ; Cystic fibrosis

    ; Celiac sprue

    ; Liver disease

Social:

    ; Travel history

    ; Ill contacts

    ; Stressors if situation determines

    ; Diet history

Pertinent review of system: urinary symptoms, respiratory symptoms

Physical Exam:

Vital signs

    ; General appearance

    ; HEENT: Eyes-sclera, oral-hydration status, if infant-fontanelles (sunken or raised)

    ; Neck: lymph nodes, thyroid

    ; Cardiac: rate, murmurs, gallops

    ; Lung: breathing pattern, breath sounds

    ; Abdomen: distention, masses, tenderness, organomegaly ; Rectal exam: if indicated

    ; Skin: rashes

    ; Extremities: pedal edema

    ; Neuro: alertness, nuchal rigidity, reflexes

Labs/ Tests: (consider)

    Electrolytes: ( if dehydration suspected)

    CBC (if blood in diarrhea)

    Stool specimen: (WBCs, blood)

    ESR (if chronic inflammatory etiology is suspected)

    Stool culture

    Stool for ova and parasites

    Other radiological testing if indicated by history and physical

Assessment:

    1. Diarrhea most likely secondary to (list your differential here)

Plan:

    1. Oral rehydration therapy

    2. BRAT diet

    3. Further workup if indicated

    4. Follow up

    5. Referral to gastroenterologist if indicated

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