What is the approach to writing a SOAP (Subjective, Objective, Assessment, Plan) note for a patient with new-onset ascites?

From the Guidelines

When writing a SOAP note for a patient with new-onset ascites, begin with the Subjective section by documenting the patient's symptoms such as abdominal distention, weight gain, shortness of breath, and discomfort, and include relevant history like alcohol use, liver disease, heart failure, or malignancy, as recommended by the most recent guidelines 1.

Approach to Writing a SOAP Note

The approach to writing a SOAP note for a patient with new-onset ascites involves several key components:

• In the Subjective section, document the patient's symptoms and relevant history.
• In the Objective section, record vital signs, weight, abdominal examination findings, and results of diagnostic tests, including comprehensive metabolic panel, complete blood count, coagulation studies, and imaging studies like ultrasound or CT scan.
• The Assessment section should identify ascites and its likely etiology, such as cirrhosis, heart failure, malignancy, or other causes, with severity grading if applicable.
• The Plan section should outline immediate management, including diagnostic paracentesis with fluid analysis, sodium and fluid restrictions, diuretic therapy, and addressing the underlying cause, as outlined in the guidelines 1.

Key Components of the SOAP Note

Some key components to include in the SOAP note are:

• Results of diagnostic paracentesis, including cell count, albumin, protein, and culture.
• Sodium and fluid restrictions, typically 2000 mg sodium/day and 1.5 L fluid/day.
• Diuretic therapy, starting with spironolactone 100 mg daily with furosemide 40 mg daily, titrating as needed.
• Follow-up plans for weight monitoring, electrolyte checks, and subsequent visits.

Recent Guidelines

Recent guidelines recommend a diagnostic paracentesis in all patients with new-onset ascites, with initial ascitic fluid analysis including total protein concentration and calculation of the serum ascites albumin gradient (SAAG) 1. The guidelines also recommend treatment of underlying disease, supplementation of protein, and restriction of salt intake to 5 g/day or less in patients with cirrhotic ascites 1. In addition, the guidelines provide recommendations for diuretic therapy, including the use of aldosterone antagonists and loop diuretics, and the management of complications such as hypokalemia, hyperkalemia, and severe hyponatremia 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Approach to Writing a SOAP Note for New-Onset Ascites

To write a SOAP note for a patient with new-onset ascites, the following components should be considered:

• Subjective:
  • Patient's symptoms and complaints, such as abdominal distension, discomfort, or shortness of breath 2
  • Recent weight gain, change in abdominal girth, and ankle edema 2
• Objective:
  • Physical examination findings, including fluid wave, shifting dullness, bulging flanks, and flank dullness 2
  • Abdominal ultrasound results, if performed 2
  • Laboratory results, such as complete blood count, liver function tests, and ascitic fluid analysis 3, 4
• Assessment:
  • Differential diagnosis of ascites, considering underlying chronic liver disease, cardiac failure, tuberculosis, malignancy-related ascites, and other causes 3
  • Classification of ascites into portal hypertension-related and non-related using the serum-ascites albumin gradient 3
  • Evaluation of the patient's condition, including the presence of complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, or refractory ascites 5, 4, 6
• Plan:
  • Management of ascites, including diuretics, sodium restriction, and/or paracenteses 5, 4, 6
  • Consideration of long-term albumin use, norfloxacin prophylaxis, and transjugular intrahepatic portosystemic shunt in selected patients 5
  • Referral for liver transplantation in appropriate candidates 4
  • Monitoring for potential complications and adjustment of treatment plan as needed 5, 4, 6