SOAP Assignment.docx - SOAP Assignment HPI location quality...

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SOAP Assignment HPI: location, quality, severity (worsening) duration timing context modifying factors and associated signs and sxs. LLQ abdominal pain for 3 days. Started off dull and he “did not think anything of it”. Now increased with nausea. Pain becoming more pronounced and unable to tolerate food or drinks.- This was in the original under Chief complaint PMH: should have a disease for every medication pt is on, also, obesity, tob (pck years)and dialy etoh use are medical dx Past Medical History : HTN and HLD. Immunizations are UTD and he receives regular checkups with his PCP. Has not undergone routine screening such as a colonoscopy (does not see the need to). Past surgical history : Left Total Knee replacement 2016 Medications: Lipitor 80mg PO daily at HS - HLD Lisinopril 20mg PO daily- HTN MVI 1 tab PO daily- Preventive health Vitals : Blood Pressure-156/78, Pulse 99 bpm, Resp 20, POX 97% RA, Pain is 7/10 Sharp, constant, nonradiating, LLQ -no increase with movement or eating, gradually worse over a few days and not relieved with OTC medications. Height is 5'6" Weight is 330lbs. BMI 53.3 Obese based on the vital signs I provided with Ht/Wt and BMI of 53.3 Does not consume ETOH or tobacco ROS: all systems and detailed for chief complaint system ROS: General: “I feel terrible” Skin: No rashes or breakdown. HEENT: Denies and change in vision, no ear pain or sore throat. No difficulty swallowing Neck: Denies any decrease in ROM Lungs: No SOB or cough. Cardiovascular: No chest pain or DOE GI: LLQ pain, Pain is 7/10 Sharp, constant, nonradiating, LLQ -no increase with movement or eating, gradually worse over a few days and not relieved with OTC medications. GU: No difficulty with urination, no lesions and no edema reported Musculoskeletal: Full ROM of all extremities Neuro: Alert and orient x 4. No change in Mental status per significant other
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This is the original ROS-this are answers to my questions. PE: only # of systems and bullets to support the code for the visit, use abbreviations PHYSICAL EXAMINATION: VITAL SIGNS: reviewed above General: Anxious, non-toxic appearance Skin: Unremarkable and no rashes noted. Left knee with scar secondary to TKR HEENT: Unremarkable. PERRLA, Lids WNL Neck: No lymphadenopathy. Supple. No JVD Lungs: Clear to auscultation bilaterally anterior and posteriorly . Respiratory Rate and rhythm is Normal and non-distressed. POX 97% on RA Cardiovascular: S1 and S2, regular rhythm. No murmur or rub. No Gallops. No periph edema noted and symmetrical pulses equal and bilaterally palpable. GI: Obese , No distention. Bowel sounds are hypoactive in all four quadrants. No distention. No pulsating masses. No Psoas or Obturator signs. The patient has left lower quadrant tenderness with moderate rebound tenderness. GU: No prostate exam warranted at this time. Scrotum without edema. Penis without tenderness or discharge EXTREMITIES: No edema, clubbing or cyanosis. Positive periph pulses noted, palpable and 2 plus. CSM is intact and capillary refill is less then 2 seconds Neuro: No focal neurological deficits .CN II-XII grossly intact without deficits . Alert and orient x
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  • Spring '18
  • Ozitz
  • Ulcerative colitis, Diverticulitis, vigorous physical activity, diverticular disease, uncomplicated sigmoid diverticulitis

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