SOAP NOTE WEEK 6

SUBJECTIVE
	CC: Elevated Liver chemistries

 

HPI: A 45 year old male present to the doctor’s office with the complaint of yellowish skin and eye that has been there for the past 14 days. He reports to be having dark urine, light-colored stools, fatigue, and anorexia. She

denies loss of appetite and vomiting.

Medications: she has not been on any medication

PMH

Allergies: NKDA

Medication Intolerances: no known history of the medication intolerance reported by the patient.

Chronic Illnesses/Major traumas: he has been diagnosed with Helicobacter pylori which was positive for gastric and duodenal ulcers 4 years ago. He was treated using eradication therapy. At present, he is not taking any medication.

Hospitalizations/Surgeries: the patients had a blood transfusion in Latvia in 2010.

Family History: mother is alive at the age of 70 years but is paralyzed after undergoing abdominal aortic aneurysm due to her smoking habit. The surgical procedure was performed in the abdominal aorta and the other in the ascending aorta. The father is dead and 68 years after being diagnosed with Alzheimer’s disease.

Social History: The patient has a history of injecting drug, smoking, and tattoos. He has been consuming between 2 glasses and 1 bottle of wine daily for many years. He is married with two daughters age 18 and 14 years.

 

 

ROS

	General: the patient denies chills, night sweats, weight change, and the change in the energy level.	Cardiovascular: denies chest pain, orthopnea, PND, palpitation, and edema.
	Skin: Discoloration of the skin (Jaundice).	Respiratory: denies cough, shortness of breathing, wheezing, pain with inspiration, chest tightness, hemoptysis, history of pneumonia or TB.
	Eyes: denies use of the corrective lenses, blurring, and change in the vision.	Gastrointestinal: denies having ulcers, abdominal pain, hemorroids, eating disorders, and tarry stools, abdominal pain, N/V/D
	Ears: denies ear discharges, ear pain, hearing losses, and the ringing of the ear.	Genitourinary/Gynecological: patient denies urgency, frequency burning, and change in the color of the urine
	Nose/Mouth/Throat: denies sinus issues, dysphagia, bleeding of the nose, dental illness, hoarseness, and the pain of the throat.	Musculoskeletal: denies back pain, stiff or pain, history of the fracture, and osteoporosis.
	Breast: denies breast lumps, bumps, or changes of the breast.	Neurological: denies weakness, paresthesias, seizures, transient paralysis, blackout spells
	Heme/Lymph/Endo: denies cold and heat intolerance, denies having an increased thirst, swollen glands, increased hunger, night sweats. Admits to be HIV negative and has been on blood transfusion.	Psychiatric: depression, excessive anger, suicidal ideation, sleeping challenges, and anxiety.
	OBJECTIVE

Weight	206 lbs BMI 26.78.	Temp 98.1 F	BP 130/98 mmHg
Height	70 inches	Pulse 70 b/min	Resp 17
General Appearance: muscular, well-nourished, and well developed. NAD level of distress, and normal ambulation.

 

Skin: Jaundice

 

HEENT: Head: normocephalic, no lesions, and no trauma. Eyes: sclerae white, conjunctivae, PERRL pupils. Ears: normal appearance of external ear with no lesions, redness, or swelling. Otoscopic examination reveals clear tympanic membrane. Nose: normal nose with no mucus, inflammation, lesion.Neck: supple,. Pharynx is non-erythematous with no exudates. Teeth in good repair.

 

Cardiovascular: regular and rhythm rate in S1 and S2, no murmurs, no rubs, no gallops, normal bilateral nor bruits present in carotid arteries, and 2+ bilateral in pedal pulses. In the extremities, there is +2 edema in the right leg, and no cyanosis.

Respiratory: unlabored and even. Clear to bilateral auscultation with no wheezing,.

 

Gastrointestinal: hepatomegaly, splenomegaly, non-tender, no bowel sounds.

 

Breast: no masses or tenderness after palpitation, no discharges, no dimpling, no wrinkling or discoloration of the skin.

 

Genitourinary: no distention of the bladder, CVA tenderness, palpable testes, no mass and lesions, no hernia, no discharges.

 

 

Musculoskeletal: right leg +2 pitting edema, no tenderness to palpitation in all other extremities, tenderness noted

Neurological: gross orientation x3, ability to communicate with normal limit, normal concentration and attention, sensation intact to light touch, normal limits of the gait, stable balance

 

Psychiatric: intact insight and judgment, logical and normal thoughts. Pleasant, calm, and cooperative. Alert and oriented ×4, maintain the eye contact, have soft speech, and has clear and normal rate and codence

Lab Tests:

CBC W/live enzyme test and hepatitis antibodies

Special Tests: ultrasound or CT Abdomen.

Diagnosis

Differential Diagnoses

· Hepatitis A: it is characterized with poor appetite, pain in the belly, mild fever, and the yellowish skin. But is ruled out since it does not cause chronic viral hepatitis

· Hepatitis C and B: transmitted through the use of the tattoo needles. The common symptoms include nausea, poor appetite, pain in the belly, mild fever, and the yellowish skin. Ruled out because of the belly pain and fever.

· Cirrhosis: late stage fibrosis of liver caused by many forms of disease such as and the chronic alcoholism

Diagnosis: Alcoholic Liver Disease: this is considered due to the history of alcohol or substance use. It is the diagnosis since the value of AST is greater than ALT (i.e. 250 against 113).

Plan/Therapeutics

o Plan:

Further testing: Imaging test needed to exclude other diagnosis

Medication: corticosteroids, calcium channel blockers, insulin, antioxidant supplements, and S-adenosyl-L-methionine

Education: nutritional counseling to reduce the risk of exposure

Non-medication treatments: management of the ALD and abstinence from alcohol to reduce the risk of alcoholic fatty liver disease

Follow-Up: follow-up monitoring of their complete blood count, renal and liver chemistries, and prothrombin time.

References

Choi, J. (2019, March 8). Alcohol-Related Liver Disease. Retrieved from Healthline: https://www.healthline.com/health/alcoholism/liver-disease

LaFlamme, M. (2018, September 17). Alcoholic Liver Cirrhosis. Retrieved from Healthline: https://www.healthline.com/health/alcoholic-liver-cirrhosis

Needs help with similar assignment?

We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

Get Answer Over WhatsApp Order Paper Now