Exam (elaborations) NR 509 Week 5 Soap Note

Exam (elaborations) NR 509 Week 5 Soap Note Initials: EP Age: 78 Gender: Female Height: 5’2” Weight: 120 lbs BP: 110/70 HR:92 Temp: 37.0 C SPO2: 99 RR: 16 Pain (1-10): 6 Allergies: Medication: NKDA Food: none Environment: Latex—“itchy rash” History of Present Illness (HPI) Chief Complaint (CC): “pain in my belly” and difficulty going to the bathroom Onset: Constipation 5 days ago with the exception of an episode of was watery diarrhea 3 days ago Location: “low in abdomen” Duration: constant x 5 days Characteristics: dull “crampy” feeling Aggravating Factors: eating causes bloating and increased pain, physical activity Relieving Factors: resting helps a little Treatment: sips of warm water which did not work NR 509 Week 5 Soap Note SOAP NOTES TEMPLATE States feeling like she needs to “rest more often” due to the pain. Current Medications Medication Dosage Frequency Length of Time Used Reason for Use Accupril 10mg Daily Unknown hypertension Past Medical History (PMHx)- Mrs. Park is a pleasant 78-year-old Korean female. She has a history of hypertension and a surgical history that is significant for cholecystectomy and one cesarean section. She is gravida three para three with two living children and one still birth by cesarean section. Her only hospitalizations were for her cholecystectomy, cesarean section and for the births of her other two children. She is unsure of date of last tetanus, immunizations up to date, has not had flu shot this year. Her last colonoscopy was 10 years ago, and the results were normal. She denies a history of constipation. She does not take vitamins or herbal supplements. She denies taking any pain medication. She does not check her blood pressure at home. Social History (SocHx)- Mrs. Park was married for fifty years, her husband, Shin died 6 years ago. She is now seeing a “gentleman friend” and is sexually active. She denies the use of contraceptives and state she has never had a sexually transmitted disease. She denies vaginal or anal intercourse but reports that they “touch and have oral sex”. She denies illicit drug use of any kind. She has never smoked and drinks one glass of dry white wine on Sundays only. She stays active with water aerobics, Pilates, walking with friends, and gardening. She lives with her daughter’s family and usually helps with household chores. Family History (FamHx)- Mother: deceased at age 88, cause of death CVA with known history of HTN, DM II Father: deceased at age 82, passed away in his sleep with known history of HTN, hypercholesterolemia, obesity Maternal grandmother: history of DM II Maternal grandfather: Died from heart attack with known history of coronary artery disease Paternal grandmother: HTN, died from cancer Paternal grandfather: died in his sleep without any known medical history Siblings: SOAP NOTES TEMPLATE Brother, 80: HTN, hypercholesterolemia, slow growing prostate CA Brother, 81: HTN Son: Healthy age 48 Daughter: Healthy age 46 Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Check if Positive Symptom Details x Fatigue States feeling like she needs to rest more frequently but denies fatigue Weakness Fever/Chills Weight Gain Trouble Sleeping Night Sweats Other Skin: Denies all symptoms Check if Positive Symptom Details Itching Rashes Nail Skin Color Other HEENT: Denies all symptoms Check if Positive Symptom Details Diplopia Eye Pain Eye redness Vision changes Photophobia Eye discharge Eye discharge Earache SOAP NOTES TEMPLATE Tinnitus Vertigo Hearing Changes Hoarseness Sore Throat Congestion Rhinorrhea Other Respiratory: Denies all symptoms Check if Positive Symptom Details Cough Hemoptysis Dyspnea Orthopnea Pain on Inspiration Other Neuro: Denies all symptoms Check if Positive Symptom Details Syncope or Lightheadedness Headache Numbness Tingling Sensation Changes RUE LUE RLE LLE Speech Deficits Other Cardiovascular: Denies all symptoms Check if Positive Symptom Details Chest pain SOB Exercise Intolerance Orthopnea SOAP NOTES TEMPLATE Edema Murmurs Palpitations Faintness OC Changes Claudication PND Other MSK: Denies all symptoms Check if Positive Symptom Details Pain Stiffness Stiffness Crepitus Limited ROM RUE LUE RLE LLE Redness Misalignment Other GI Check if Positive Symptom Details Nausea/Vomiting Denies Dysphasia Denies x Diarrhea Last bowel movement was an episode of watery diarrhea 3 days ago X Appetite Change decreased Heartburn Denies Blood in Stool Denies X Abdominal Pain Dull and cramping X Excessive Flatus Reports more than normal Food Intolerance Denies Rectal Bleeding Denies Other Last colonoscopy 10 years ago, results normal Typically has bowel movements daily, usually soft SOAP NOTES TEMPLATE and formed GU Check if Positive Symptom Details Urgency Denies Dysuria Denies Burning Denies Hematuria Denies Polyuria denies Nocturia denies Incontinence denies Other States slightly less urination than normal but thinks it is due to her “drinking less than normal” PSYCH: Denies all symptoms Check if Positive Symptom Details Stress Denies Anxiety Denies Depression Denies Suicidal/Homicidal Ideation Memory Deficits Mood Changes denies Trouble Concentrating Other: GYN: Denies all symptoms Check if Positive Symptom Details Rash Discharge Normal Itching Irregular Menses Dysmenorrhea Foul Odor Amenorrhea LMP Menopause onset at age 54 Contraception None Other: Menopause at age 54 Sexually active with “gentleman friend” but denies SOAP NOTES TEMPLATE vaginal or anal intercourse. Reports that they “have oral sex and ‘touch’ Hematology/Lymphatics: Denies all symptoms Check if Positive Symptom Details Anemia Easy bruising/bleeding Past Transfusions Enlarged/tender lymph node(s) Blood or lymph disorder Other: Endocrine: Denies all symptoms for this system Check if Positive Symptom Details Abnormal growth Increased appetite Increased thirst Thyroid disorder Heat/cold intolerance Excessive sweating Diabetes Other: O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Body System Positive Findings Negative Findings General Patient is well groomed, interactive and cooperative. Face and head are normocephalic and symmetrical Skin Cheeks are slightly flushed; skin is wrinkled as expected with age, but no tenting is noted. Skin pink, warm, dry, and intact. SOAP NOTES TEMPLATE There is no tenting. Her hair is evenly distributed and grey in color. HEENT Nasal septum pink and moist, mouth and throat pink and moist, did not inspect ear canal but ears are symmetrical and even Respiratory Lungs clear to auscultation throughout, patient in no distress, denies dyspnea Neuro Alert and oriented, able to follow commands Cardiovascular Auscultated heart sounds with bell and diaphragm of stethoscope, S1 and S2 noted without evidence of any gallops, murmurs, rubs or clicks. No additional heart sounds noted. Aorta palpated at 2cm, no lateral pulsation, no bruit with auscultation. Auscultated Renal, Iliac, and Femoral arteries bilaterally without bruit noted. No friction rub noted over liver or spleen. No evidence of any edema noted in lower extremities Musculoskeletal Gastrointestinal Dullness was noted over left lower quadrant with percussion Patient reacted to pain in left lower quadrant upon light and deep palpation with distention noted as well as noted firm oblong mass 2cmx4cm to the LLQ Pain evidenced by guarding Bowel sounds normoactive in all quadrants with auscultation. Abdomen is symmetric and flat, 1 st horizontal scar noted in right upper abdomen just below right costal margin, 2nd horizontal scar noted approx. 1 cm above pubic girdle Liver palpated 1cm below tight costal margin with dullne