(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)M. Miller SOAP WEEK 4 Patrick Smith Age 42 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 Genitourinary: not reviewed Gastrointestinal: No reports of heartburn, or indigestion, endorses nausea Musculoskeletal: not reviewed Hematologic: not reviewed Endocrine: not reviewed 1 | P a g eObjective VS T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%. 5 feet 9 inches weight: 195 pounds BMI 28.8 Urinalysis: Positive WBCs, Small blood. Trace protein, pH 7.0 specific gravity 1.030, negative nitrites, negative ketones, negative glucose CBC: WBC 6000 mm3 RBC 5 million Hbg 15g Hct 46% MCV 90 fL MCHC 35 g/dL Ultrasound report: 5mm smooth round calculus is noted at the junction of the ureter and the bladder Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution throughout scalp. Sclera clear, conjunctiva white. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen appears slightly distended, symmetric with no visible masses. RLQ scar noted. Decreased bowel sounds noted. No vascular sounds. Tympany noted in all four quadrants on percussion. Abdomen is soft, no organomegaly, no masses or tenderness. Positive CVAT on right side. Assessment: Urolithiasis (ICD 10: N21.9)- Frassetto and Kohlstadt (2011) report that plaques are composed of calcium phosphate/apatite deposits, localized to the basement membrane of the thin loop of Henle and extending into the papillary interstitium. When these plaques form, they erode through the urothelium and constitute a stable, anchored surface on which calcium oxalate crystals can nucleate and grow as attached stones (Frassetto & Kohlstadt, 2011). This patient is believed to have nephrolithiasis as he complains of acute severe flank pain, nausea, urinary frequency, groin pain, and costovertebral angle tenderness. In addition, the ultrasonographer has stated the patient has a 5mm stone which is present at the junction of the ureter and the bladder. The location of the stone is known as ureterovesical junction. Lastly, the urinalysis identified hematuria to further support the diagnosis. 2 | P a g ePlan Prescriptions Dispense: #90 Dispense: #30 Additional diagnostic tests 24- 2014) MRI is also useful in detecting scarring. In adults, it is increasingly used where by cost and availability (Pearle et al., 2014). 3 | P a g efluid intake evenly to maintain dilute urine at all times. A daily fluid intake of 2-3 liter is needed to help minimize stone formation. Ingestion of cranberry juice has been shown to decrease urinary oxalate and urinary phosphate increase urinary citrate and decrease relative supersaturation (Pearle et al., 2014). Patients should be advised to avoid soda as the phosphoric acid within the drink may contribute to stone reoccurrence (Pearle et al., 2014). Lastly, long periods of immobilization should be avoided (Pearle et al., 2014). a. It is important to call the health care provider if: • Decreased urine output or trouble urinating • Continued severe pain in the lower back or flank • Fever above 101.5°F or shaking chills • Dark-colored or foul-smelling urine • Nausea or other problems that prevent you from taking your prescribed medication 3. Referral for imaging or cystoscopy should be considered in patients who: • Have persistently not responded to treatment. • Have a history of renal tract disease or anomaly. • Have hematuria. • Are men with two or more episodes in three months Patients with urinary calculi along with fever and other signs or symptoms of infection need emergency urologic consultation for drainage and intravenous (IV) antibiotics. Failure to perform rapid renal decompression can perpetuate urosepsis and result in death (Pearle et al., 2014). Further treatment is aimed at the particular stone the patient has so when the patient passes a stone please attempt to catch it in a strainer if possible. Because there are several types of kidney stones and the causes for each vary, knowing this information is critical in determining the best course of treatment and prevention, including medical management of the condition on an ongoing basis. 4. Plan to follow up a. Repeat urine cultures in one to two weeks after completing therapy. An in office or phone consultation within ten days to discuss results of repeat tests, resolution of symptoms, or nonresolution of symptoms. As well as further urologic evaluation after the first episode of pyelonephritis and with recurrences. 4 | P a g e5 | P a g eAdditional questions presented in part two week four Calculate Patrick’s BMI, does the finding impact his diagnosis or treatment? Patrick’s BMI is 28.8 and is concerning, as he is considered overweight. Urinary uric acid is a risk factor for calcium oxalate stones and is also positively associated with obesity. According to Semins et al. (2010) higher serum uric acid levels in obese individuals may result from increased uric acid production, decreased renal excretion, or both. It is important for this patient to learn to lower his weight through diet and exercise. What should the NP do if Patrick continues to come back for pain medication? According to Clark, Wilder, and Winstanely (2014) utilization of an opioid risk tool is important on the initial visit prior to beginning opioid therapy for pain management tends to produce better outcomes in patient care. For example, utilizing the opioid risk tool a score of 3 or lower indicates low risk for future opioid abuse, a score of 4 to 7 indicates moderate risk for opioid abuse, and a score of 8 or higher indicates a high risk for opioid abuse (Clark et al., 2014). According to Clark et al. (2014) patients with substance abuse issues can be treated for pain in a variety of ways that don’t involve opioid medications. For example, suggesting and