GI Soap Note Case

GI Soap Note Case

Complete visit 1 and visit 2 for this assignment

Visit 1

A 34-year-old black female reports to clinic with c/o chest pain and leg cramps.  The patient was seen by a GI specialist and was informed that she had hemorrhoids and was prescribed rectal suppositories for hemorrhoids.  The patient returned to the GI doctor, and he indicated that the rectal bleeding did not resolve.  The GI specialist performed a colonoscopy, and the patient was diagnosed with Crohn’s disease.  The patient was started on Remicade infusions for Crohn’s disease about 3 weeks ago.  The patient is currently in remission and reports no rectal bleeding.

Vital Signs:  B/P 148/94, Resp 20, Temperature 99.4, O2 sat 95%, Pulse 99

Cramps in legs can be painful at times with a current pain score of 2 today in office.

No known diagnostic allergies

SH:  Quit smoking 3 weeks ago after after starting Remicade.  The patient smoked 1 pack of cigarettes per day since age 20.

Check tips on how to do your Nursing Homework. 

GI Soap Note Case

FH:  Mom passed away of a MI at age 40 years old.  Father is alive and is doing well.  Father has HTN controlled by Hydrochlorothiazide.  No family history of GI disorders.

Your SOAP Note should include:

1. What are some additional questions would you ask the patient?
2. What are possible serious complications to Remicade?
3. Provide differential diagnoses for chest pain and differential diagnoses for leg pain.
4. Prioritize your plan of care for patient.
5. What immediate actions would you take for this patient?

Visit 2 (a SOAP note is not required for part 2, please answer questions)

The patient returns to your clinic after being hospitalized for 3 days in hospital.  The patient was ordered to follow up with their primary care provider post hospitalization.  The patient reports feeling better. The patient was started on an anti-hypertensive medication HCTZ 12.5 mg daily.  The patient’s cholesterol was 280 and the GI specialist recommended to follow up with primary care provider to start cholesterol medication.  The patient states that she is struggling with anxiety and depression because of her diagnosis of Crohn’s disease.  The patient has never taken medication for anxiety or depression but is requesting medication.

GI Soap Note Case

  No suicidal ideation per patient.

1. What lab values can be ordered to monitor patients with Crohn’s disease?
2. What lab values would you order for patient during this follow-up visit?
3. Once the NP receives lab results and cholesterol and lipid levels remain elevated what cholesterol medication would you start patient?
4. When should the patient’s cholesterol level be monitored after starting dose?
5. Crohn’s disease can alter the metabolism of lipids, primarily cholesterol levels. True or False
6. What medication would you prescribe for patient for anxiety and depression.
7. What medications worsen Crohn’s disease?

Content must be supported with current evidence-based clinical practice guidelines