Exam (elaborations) (SOAP NOTE) NR511 WEEK 4 M. MILLER Patrick Smith 42 YO(CC Pain in back and abdomen)

(SOAP NOTE) NR511 WEEK 4 M. MILLER Patrick Smith 42 YO(CC Pain in back and abdomen) Subjective Chief complaint: “I am in a lot of pain in my back and abdomen” History of present illness (HPI): O: Onset- 5 am L: Location—initially pain begin on the side of his back; and now there is also pain in his stomach D: Duration-intermittent pain that comes in waves C: Characteristics/Associated symptoms- throbbing, feels nauseated, urinary frequency, sweaty, pain that and at times shoots down to the groin A: Aggravating factors -sitting in the office R: relieving factors- nothing T: Treatments- used Tums and they were not effective, nor was position changes S: Severity- rated 8/10 Past Medical History- NKDA. Immunizations UTD. Describes health as good. Has hay fever and psoriasis, medication which was given at last visit worked, not using at this time. No previous back injuries. No daily medications. No herbal medication use. Had his appendix out at age 10. Previous hospitalization for broken leg requiring traction at age 8. Family History- Parents are deceased. Mother died at age 51 from a brain tumor and father died age 53 leukemia. Has one brother in good health. Social History- Married, has four children. Lives with his immediate family and in-laws. Works full time as a plumber. Work has been so busy no time lately for regular exercise. Smokes cigarettes, a pack a day. No ETOH or illicit drug use. Sleeps 5-6 hours a night. Review of Systems: Neurologic: no report of further headaches, denies dizziness Head/Eyes/Ears/Nose/Mouth/Throat: No report of nasal congestion, or discharge, denies lymph node enlargement Integumentary: not reviewed Cardiovascular: denies palpitations Respiratory: No report of wheezing or shortness of breath with rest