NR 511 SOAP week 4

05 August 2024

SOAP Note – Week 4

Patient Name: Patrick Smith Age: 42 Date: [Insert Date] Clinician: MMiller

Subjective

Chief Complaint: “I am in a lot of pain in my back and abdomen.”

History of Present Illness (HPI):

  • Onset: Began at 5 am today.
  • Location: Initially started on the side of his back; pain is now also in the stomach.
  • Duration: Intermittent pain that comes in waves.
  • Characteristics/Associated Symptoms: Throbbing pain, nausea, urinary frequency, sweating, and pain that occasionally radiates to the groin.
  • Aggravating Factors: Sitting in the office.
  • Relieving Factors: No relief from any interventions.
  • Treatments: Tried Tums and position changes, but they were ineffective.
  • Severity: Pain rated at 8/10.

Past Medical History:

  • Allergies: NKDA (No known drug allergies).
  • Immunizations: Up to date.
  • Health Description: Generally good health.
  • Conditions: Has hay fever and psoriasis, both well-managed.
  • Surgeries: Appendix removed at age 10.
  • Hospitalizations: Previous hospitalization at age 8 for a broken leg requiring traction.
  • Medications: No current daily medications or herbal supplements.

Family History:

  • Mother: Deceased at age 51 due to a brain tumor.
  • Father: Deceased at age 53 due to leukemia.
  • Siblings: One brother in good health.

Social History:

  • Marital Status: Married, has four children.
  • Living Situation: Resides with immediate family and in-laws.
  • Occupation: Works full-time as a plumber.
  • Exercise: Lack of regular exercise due to a busy work schedule.
  • Substance Use: Smokes one pack of cigarettes per day. No alcohol or illicit drug use.
  • Sleep: Sleeps 5-6 hours per night.

Review of Systems (ROS):

  • Neurologic: No recent headaches, denies dizziness.
  • Head/Eyes/Ears/Nose/Throat (HEENT): No nasal congestion, discharge, or lymph node enlargement.
  • Integumentary: Not reviewed.
  • Cardiovascular: Denies palpitations.
  • Respiratory: No wheezing or shortness of breath at rest.
  • Gastrointestinal: Denies heartburn or indigestion; endorses nausea.
  • Genitourinary: Not reviewed.
  • Musculoskeletal: Not reviewed.
  • Hematologic: Not reviewed.
  • Endocrine: Not reviewed.

Objective

Vital Signs:

  • Temperature: 98.9°F
  • Blood Pressure: 160/96 mmHg
  • Pulse: 100 bpm
  • Respiratory Rate: 22 breaths per minute
  • Oxygen Saturation: 98%
  • Height: 5 feet 9 inches
  • Weight: 195 pounds
  • BMI: 28.8

Physical Examination:

  • General: Alert, oriented, and cooperative.
  • HEENT:
    • Head: Normocephalic, hair thick and well-distributed.
    • Eyes: Sclera clear, conjunctiva white.
    • Ears: Tympanic membranes gray and intact with light reflex; pinna and tragus non-tender.
    • Nose: Nares patent without exudate.
    • Throat: Oropharynx moist, no lesions or exudate, tonsils 1+/4 bilaterally.
    • Teeth: In good repair, no cavities noted.
    • Neck: Supple, no lymphadenopathy, thyroid midline, small, and firm without palpable masses.

Laboratory Results:

  • Urinalysis:
    • Positive for WBCs, small blood, trace protein.
    • pH 7.0, specific gravity 1.030.
    • Negative for nitrites, ketones, and glucose.
  • CBC:
    • WBC: 6,000/mm³
    • RBC: 5 million/mm³
    • Hemoglobin: 15 g/dL
    • Hematocrit: 46%
    • MCV: 90 fL
    • MCHC: 35 g/dL

Imaging:

  • Ultrasound Report:
    • 5mm smooth round calculus noted at the junction of the ureter and the bladder.

Assessment

Primary Diagnosis:

  • Ureteral Calculus (Kidney Stone): The patient’s symptoms of severe, intermittent, throbbing back and abdominal pain that radiates to the groin, along with the presence of a 5mm calculus on ultrasound, are consistent with a diagnosis of ureteral calculus. The urinalysis findings of blood and WBCs further support this diagnosis.

Differential Diagnoses:

  • Pyelonephritis: The presence of WBCs in the urinalysis suggests a possible urinary tract infection, but the lack of fever and systemic symptoms makes pyelonephritis less likely.
  • Musculoskeletal Pain: Given the patient’s occupation as a plumber, musculoskeletal pain could be a consideration, but the characteristics and location of the pain are more suggestive of a renal origin.

Plan

Diagnostic Testing:

  • Consider a non-contrast CT scan of the abdomen and pelvis to further evaluate the size and location of the kidney stone and assess for any possible complications.

Medications:

  • Pain Management: Prescribe NSAIDs such as ibuprofen for pain relief.
  • Antiemetic: Prescribe an antiemetic such as ondansetron for nausea.
  • Hydration: Encourage increased oral fluid intake to facilitate the passage of the stone.

Patient Education:

  • Educate the patient on the importance of hydration and advise him to monitor his urine for any changes or the passage of the stone.
  • Discuss potential symptoms that would require urgent follow-up, such as fever, worsening pain, or inability to urinate.

Follow-up:

  • Arrange a follow-up appointment in 1-2 weeks or sooner if symptoms worsen, to reassess pain, check for the passage of the stone, and consider further intervention if needed.

Lifestyle Modifications:

  • Encourage the patient to quit smoking and discuss the potential benefits of smoking cessation for overall health and kidney stone prevention.

Signature: MMiller, [Your Title] [Your Contact Information]