Create a SOAP note for a FOCUSED exam Case #3 SUBJECTIVE: CC: “I am… Create a SOAP note for a FOCUSED exam Case #3 SUBJECTIVE: CC: “I am having black stool and tiredness”. HPI: A 68-year-old white male presenting with complaints of black stool for the past two to three days whom brought a sample into clinic today. He is also complaining of feeling “sluggish and fatigued”. He reports no bad smell noted with stool or diarrhea. He became concerned when he noted a red ring forming when the stool “hit the water”. He had some musculoskeletal discomfort a couple weeks ago for which he was prescribed Lodine. He reports he took it for one week and then discontinued the use of due to problems resolving. He reports an uncomfortable feeling in the RUQ at times describing it as just an achy feeling such as gas and relieved with movement. He reports no dyspepsia or GERD. He reports no exacerbating factors. He reports taking no OTC medications for relief. He reports he had a colonoscopy in six months ago with the result indicating some diverticulosis but no polyps. The stool brought in is dark and Heme positive. PMH: Chicken pox as a youth, hyperlipidemia and hypertension Allergies: NKDA Medications: He reports taking Amlodipine 2.5mg tablets daily for hypertension and an occasionally daily multivitamin for men. He reports he has not had to take any medication for hyperlipidemia for the past eight months as he has controlled it with his diet. Surgical history: Reports orthopedic surgery in January 2014 for dislocated left shoulder, from an incident with a tractor rolling over Social history: Married with and self employed as a pastor and co-owner in the new local ambulance service. He has two adult sons in their 30s. He reports he does not smoke nor has he ever, does not consume alcohol, does not use illicit drugs nor has he ever. Reports heavy intake of caffeine with coffee four to five cups daily. Family history:Wife – 67 yo, alive with hypertension and seasonal allergies Son – 36yo, alive with ulcerative colitisFather deceased at 79 with CVA Mother deceased at 87 with CHF Health Maintenance/Promotion: He reports he believes his childhood immunizations were received once he was an adult. Received influenza vaccine last flu season. Had T-dap in 2017. He follows up with his family physician yearly and with cardiology as needed. Has received the Hep B vaccine series in 2017. He had a yearly TB screening in February 2019 which was negative. Received Pneumococcal vaccine at age 65. He reports he received the zoster vaccine at age 62 on his birthday. He wears glasses with bifocals with the last exam being February 2019. He had dental exam September 2020. Received colonoscopy six months ago. Does not exercise regularly. He is in the process of building his new home. REVIEW of SYSTEMS: General: Denies fever, chills, night sweats, or weight change. Skin: Denies skin rashes, lesions, dryness, or itching, reports scar to left shoulder. HEENT: Denies headaches, migraines, head trauma, nodules to scalp. He reports frontal hair loss has been over the past 20 years with recent changes to hair texture or fingernails. Denies light-headedness, reports occasional dizziness upon standing for the past few days but quickly resolves. Denies any facial pain or numbness. Denies eye discharge, spots, or double vision. Denies cataracts. Reports eye dryness with use of artificial tears occasionally.Denies ear pain or drainage. Reports hearing loss in both ears. Denies nasal discharge, epistaxis or difficulty with smell. Denies throat pain or difficult swallowing. Denies tongue or gum disorder. Reports full upper and lower denture set. Denies jaw pain. Neck: Denies pain, lumps, or neck stiffness. CV: Denies shortness of breath, dyspnea on exertion, chest discomfort, tightness, palpitations, irregular heartbeat, murmurs, or edema. Denies orthopnea. Lungs: Denies cough, wheezing, inability to take deep breath, or hemoptysis. GI: Reports uncomfortable feeling to RUQ at times. Denies dyspepsia or reflux disease. Denies abdominal distention, nausea or vomiting. Denies constipation or diarrhea. Reports black stools with red color. Denies excessive hunger or thirst. GU: Denies dysuria, hematuria, urinary frequency, decrease stream, or urgency. Denies flank pain or history of kidney stones. PV: Denies extremity swelling, tingling, or numbness. Denies calf tenderness. Denies bleeding disorders. MSK: Denies joint or back pain, denies muscle problems. Denies arthritis. Denies unsteady gait or decrease in range of motion. Neuro: Denies sensory problems, weakness, stroke, seizures, tremors, or numbness. Denies problems with walking or standing for periods of time. Denies history of falls. Denies memory loss. Endo: Denies hot or cold intolerance. Psych: Denies tension, nervousness, depression, anxiety, or suicidal ideations. OBJECTIVE: General: A 68-year-old, well nourished, well-groomed polite white male with clear spoken words and strong thought process with current and remote memory, decision, and cognitive making unimpaired. He is alert and oriented to person, place, time and situation, in no acute distress. VS: TEMP – 97.2, B/P – 129/83 sitting (L arm), P – 73, RR- 18, O2SAT – 99% (Room Air), Height – 5ft 6in, Weight – 202lbs, BMI – 32.6. SKIN: Warm and dry, face symmetrical pale in color, skin turgor with slight tenting noting lasting longer than three seconds. No discolored spots, lesions, or rashes present to face, neck or lower forearms. HEENT: Clean cut gray colored hair well managed with thinning to crown and frontal areas, no palpable nodules or deformities to scalp. No maxillary tenderness. Masseter and temporal muscle strength noted to be equal upon smile. Some skin looseness noted around mouth creases. Use of glasses noted. Eyes equally round and reactive to light with bilateral pupil size at 2mm, white scleral and clear conjunctiva, ptosis noted bilateral otherwise external structures appear normal. No periorbital edema, extraocular movement evident using pen and air H. Bilateral external auditory canals free from drainage, tympanic membranes with no redness or bulging, landmarks are visible bilateral. There is bilateral hearing loss noted with soft whisper voice. Nasal turbinates are clear, no lesions or bleeding, no septum deviation, no obstruction. Mucus membranes moist and pink, no ulcers noted to gums, the gums and tongue are moist and pink with proper movement, full set of dentures are noted. No exudate, lesions, or erythema noted to throat, uvula is midline. Trachea and thyroid are midline, neck supple and non-tender, no bruits, no submandibular, anterior cervical nodes, or posterior cervical nodes palpated. No shoulder drooping. CV: Normal S1 and S2 with regular rate and rhythm, no murmurs, rubs, or gallop rhythms. PMI mid clavicular line. Lungs: Bilateral symmetric chest excursions with normal appearing chest wall. Clear bilateral breath sounds with no rales, rhonchi, or wheezing anteriorly or posteriorly. No retraction or signs of respiratory difficulty. ABD: Soft, large, non-tender, non-distended abdomen with hyperactive bowel sounds times four quadrants, no ascites, no epigastric tenderness, no hernia’s or masses palpable, no hepatomegaly, flank tenderness, or costovertebral angle tenderness. No renal bruits. GU: Omitted PV: No lower extremity edema or discoloration. No noticeable deformities. Radial and pedal pulses strong, equal, and regular. No clubbing noted. MSK: No CVA tenderness, no defects or deformities noted. There is ability to bend and extending back and waist. Good upright posture positioning and alignment present. There is full range of motion noted. Equal bilateral hand grips strong. Neuro: Gait is normal. Deep tendon reflexes 2/4 symmetric triceps, biceps, BR, and ankle. Motor 5/5 throughout, sensory intact with cranial nerves 2-12 intact. Good tone, moves all extremities without difficult. Psych: Good mood and affect noted. Good speech and voice. No agitation or anxiousness present at visit. Diagnostic Tests:Hemocult = positiveH/H revealing 12.3/37 and Platelet count of 269 Health Science Science Nursing NU MISC Share QuestionEmailCopy link Comments (0)
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