SOAP Advanced Health Assessment
Please find the assignment for this weeks case study soap note analysis.
- CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
- HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
- PMH: HTN, Diabetes, hx of GI bleed 4 years ago
- Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
- Allergies: NKDA
- FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
- Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
- VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
- Heart: RRR, no murmurs
- Lungs: CTA, chest wall symmetrical
- Skin: Intact without lesions, no urticaria
- Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
- Diagnostics: None
- Left lower quadrant pain
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
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