Soap Note: Advanced Client Assessment Essay

1035 words - 4 pages

Patient name: MR.
CC: LUQ abdominal pain.
HPI: MR is a 70 y.o. male patient who presents to ER with constant, dull and RUQ abdominal pain onset yesterday that irradiate to the back of right shoulder. Client also c/o nauseas, vomiting and black stool x2 this morning. He reports that currently resides in an ALF; they called the ambulance after his second episodes of black stool. Pt reports he drank Pepto-Bismol yesterday evening without relief. Pt states that he never experienced similar symptoms in the past. Denies any CP, emesis, hematochezia or any other associated symptoms at this time. Client was found with past history gallbladder problems years ago.
Review of symptoms:
General: denies weight loss, insomnia, fever or chills.
HEENT: no headache, no tinnitus, no hearing loss, mouth sores, no voice changes, no problems swallowing, sinus congestion, no visual disturbances.
Cardio: no known murmur, palpitations or chest pressure/ pain.
Respiratory: negative for S.O.B, cough or hemoptysis.
GI: Positive for abdominal pain RUQ, nauseas and vomiting x2 today in a.m. hours, also black stools x2.
GU: negative for dysuria, urgency, hematuria or flank pain.
Hematology/ Lymph: Negative for bleedings problems or swollen lymph nodes.
Musculoskeletal: Negative for myalgia, arthralgia or falls.
Neuro: Negative for dizziness, tingling, sensory changes and loss of consciousness.
Mental/Psych: Negative for depression or psychiatric problem.
Allergies: NKDA
-Amlodipine (Norvasc) 10mg po QD.
-Glipizide (Glucotrol) 10mg po BID.
-Metformin (Glucophage) 1000mg po QD
-Simvastatin (Zocor) 20mg po QHS
-Pantoprazole 40mg po QD
-Donepezil (Aricept) 10mg QD
Past Medical History: -HTN.
Past Surgical History: -Appendectomy in childhood.
Family Medical History: -HTN in parents and grandparents.
Social history: Patient was born in Cuba, migrates to USA in 1994. Single
Former smoker. No drugs or alcohol.

Subjective Analysis:
The clinical presentation of constant, dull pain localized at abdomen RUQ, that irradiate to the back of right shoulder with nauseas, vomiting and black stool x2 is a common presentation of Acute Cholecystitis. According to Davidson (2010) “Pain location associated w/ vomiting and nauseas are the most common presenting symptom of Cholecystitis most of the time associated with Cholelithiasis”.
VS: HR: 110, BP: 152/90, Rasp: 18, Temp: 98.3 oral, Glyc: 145, SpO2: 97%
Physical exam:
General appearance: Patient alert in no distress, well-nourished and well developed.
Neck: Supple, no adenopathy, thyroid not enlarged and no carotid bruits.
Heart: Regular rate and rhythm without murmurs.
Lungs: Clear to auscultation bilaterally. Normal breath sounds.
Abdomen: Tender at middle and RUQ of the abdomen, Boa’s sign and Murphy sign positive. BS present and normal.
Extremities: no cyanosis,...

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