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Objectives:

1. Identify components of system-based physical examinations.

2. Critique SOAP notes for missing history elements. 

3. Identify the pathophysiology of an identified disease process and its relationship to assessment findings for individual patients. 

4. Differentiate pertinent findings in a patient’s health history and physical examination. 

5. Identify sources for clinical decision making for use in the assessment of patients.

 

 

SOAP Note:

Date    

09/21/17                     

 

Pt Identity 

J.G., 56 y/o male, seems reliable. Prior medical records reviewed.

 

Chief Concern

“I’ve had diarrhea for about a week or so.”

 

History of Present Illness

Having 5-10 soft unformed light-brown stools per day (including overnight), which started suddenly 7 days ago. He has not had diarrhea this bad before. Has not identified a relationship between diarrhea and food or fluid intake. Some relief from Imodium and Pepto-Bismol. Also reports 3-day history of increased hemorrhoidal bleeding during defecation w/ perianal burning and itching for about 20 minutes after each BM. Denies direct contact with anyone experiencing similar symptoms, recent travel, and dietary changes. Started taking metformin 500 mg BID 2 weeks ago. Has h/o irritable bowel syndrome, previously well-controlled on Bentyl. 

 

Past Medical History

Adult Illnesses

HTN for “around 15 years” – controlled on lisinopril/HCTZ

Irritable bowel syndrome “since I was a teenager” – Bentyl 

T2DM, diagnosed 2 weeks ago – BG stable on metformin

Sinus tachycardia for “about a year” – controlled on metoprolol

Denies CA, CAD, CVA, and HLD.

 

Health Maintenance

Colonoscopy ordered last year, not done d/t fear of bowel prep causing incontinence.

Vaccines “up to date” per patient. Has not had hepatitis B vaccine. 

 

Childhood Illnesses

IBS, as noted above. 

 

Surgical History

None reported.

 

Family History

Uncle died age 47, colon cancer. Otherwise noncontributory. 

 

Accidents/Injuries

Denies.

 

Hospitalizations

Denies.

 

Psychosocial History

Married, 3 grown children. Works as a high school science teacher w/ intermittently high stress, but has not noticed an increase recently. Denies h/o military service. 

Denies smoking, alcohol, and recreational drug use. 

Monogamous sexual partner, denies current or prior receptive anal intercourse or rectal-oral sexual practices. 

Denies recent domestic or international travel, camping/hiking, and fishing/hunting. Denies owning pets. 

 

Allergies

NKDA. Denies environmental and food allergies. 

 

Current Medications

Lisinopril/HCTZ 20/12.5 daily. Last dose this morning.

Dicyclomine (Bentyl) 40 mg q6h. Last dose this morning.

Metformin 500 mg BID. Last dose this morning.

Metoprolol 50 mg BID. Last dose this morning.

Acetaminophen 1000 mg PRN for “aches and pains”. Last dose 2 days ago.

 

Review of Systems

General: Denies weight change, fever, chills, night sweats, fatigue, weakness, and changes in appetite.

Skin: Denies rashes, ulcerations, dryness, flaking, and excessive sweating.

Pulmonary: Denies cough, dyspnea, increased sputum production, hemoptysis, snoring, and wheezing.

Cardiovascular: Denies chest pain, palpitations, orthopnea, PND, known heart murmurs, edema, intermittent claudication, leg cramps, and varicose veins. 

GI: Reports diarrhea, perianal burning and itching, and bright-red blood on toilet paper, as described above. Reports history of hemorrhoids. Denies N/V, indigestion, abdominal pain or cramping, excessive flatulence, bloating, fecal incontinence, constipation, anal trauma, and dark tarry stools. Last BM was 15 minutes before appointment, light brown, soft and unformed. 

Psych: Denies feeling depressed, nervous, or anxious.

 

PHYSICAL EXAM

Constitutional: Appears well-groomed, well-nourished, and well-developed. Sitting comfortably in exam room chair. T 98.1F (oral), HR 114, RR 16, BP 118/99 (right). BMI 28.4. 

Skin: Exposed skin is smooth, free of lesions, bruising, tattoos, and piercings. 

Lungs/Thorax: Rate regular and unlabored. No accessory muscle use. Lung sounds clear and equal bilat. Resonant in all lung fields. Nail beds pink w/o clubbing. 

Cardiovascular: Regular rate/rhythm w/o clicks, gallops, rubs, S3, S4, or murmurs. Pedal pulses 2+ bilat. Skin warm, dry. No edema.

Abdomen: Round, soft, symmetrical, w/o masses, lesions, or hernia. Bowel sounds hyperactive x4 quadrants. Resonant w/ gastric tympany. No tenderness or rigidity on light and deep palpation. No renal/aortic/iliac bruits. 

Psych: Affect bright and appropriate. 

 

 

 

 

 

 

 

 

4. There is at least 1 system missing from the Physical Exam that is relevant for this acute visit. Which system is missing, and what problem(s) are you specifically looking for? 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING MS N595

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