SOAP Note 6

Subjective: 48 y/o female with recent admission to QHC for acute perforated diverticulitis with abscess formation, s/p CT guided drainage of peri-colonic abscess with drainage catheter placement on 9/5/23, presents to proctology clinic for initial post-hospital visit. Pt states she is feeling well and has completed antibiotics given to her in the ER. Notes having one episode of abdominal pain after eating seafood, but then had BM and pain resolved. Pt also notes she has a pigtail in place that stopped draining 2 days ago (last recording on 9/17/23 showed 5mL). Pt denies abdominal pain, fever, chills, nausea, vomiting, and rectal bleeding.

Objective:

Physical Exam:

Vitals: BP: 120/70         HR: 96        Temp:36.1  SpO2: 97% Wt:85.3 kg Ht: 4’9”      BMI: 40.68

Abdomen: obese and symmetric, non-distended, no scares, striae, or pulsations noted. Pigtail drain in place LLQ with no output or surrounding erythema, swelling or drainage. Abdomen soft. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. No tenderness to palpation, (-) guarding, (-) obturators sign, (-) psoas sign, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Assessment: 48 y/o with h/o acute perforated diverticulitis with abscess formation, s/p CT-guided drainage of pericolonic abscess with drainage catheter placement on 9/5/23, feeling well with no active complaints. Consider pigtail removal as patient asymptomatic, and re-evaluate in a few weeks to see if pt remains asymptomatic in order to schedule follow up colonoscopy. 

Plan:

  • Pt to see radiology today to have pigtail removed
  • Discussed management plan with patient and explained that colon resection may be needed in the future if symptoms worsen or continue to recur. Will continue to monitor patient’s symptoms
  • Pt to return in 2-3 weeks to re-evaluate. Will plan for colonoscopy at next office visit if symptoms completely resolved
  • Pt advised to return to ER if develops fever, chills, severe, abdominal pain, rectal bleeding, or has any other concerning signs or symptoms. Pt expresses understanding.