SOAP NOTE
SUBJECTIVE (S)
Patient Name: Tommy JacksonAge: 18DOB: unknown Sex: MaleDate of Visit: January 24, 2022
Chief Complaint: “I have this horrible pain in my belly”
History of Present Illness (HPI): This is an 18-year-old Caucasian male that presents with abdominal pain that started about 5 hours ago while playing tennis. Patient indicates the pain is located in his lower right side and feels like “burning and a cramp at the same time”. Patient believed it was a pulled muscle but after sitting down to rest, the pain did not go away. Patient states the pain is worse if he tries to “straighten up” and pain feels better when “bent forward”. Patient describes the pain as “the worst pain I ever had.” Pain is continuous and does not radiate. Patient reports associated nausea. Patient indicates he drank 7up soda which made him feel worse. No other treatments were tried. Patient denies vomiting, diarrhea, and fever.
Past Medical History (PMH): Childhood Illnesses: NoneAdult Illnesses: NoneMedical: NoneSurgical: Rhinoplasty 1/23/2022Allergies: NKDACurrent Medications: Cephalexin 500mg BID PO daily (duration unknown, started yesterday); Acetaminophen and Codeine PRN for pain (dose, frequency, and duration unknown; for post-op ENT surgery pain); Acetaminophen PRN for headaches (dose and frequency unknown) Health Maintenance, Immunizations, Exercise: unknown if patient has PCP; up to date on all immunizations; exercises 3 days a week for 2 hours.Family History: NonePsychosocial History: Tommy is a senior in high school. He lives at home with his parentsand two older brothers. States he “lives in a nice house in a good part of town”. He works at McDonalds on Saturdays and enjoys exercise and hanging out with his friends. He drives his mom car when he needs to go somewhere. He denies alcohol use, tobacco use, and illicit drug use. Tommy is sexually active. He denies any hospitalizations, psychiatric conditions, or suicidal ideations. Diet: Patient drinks 1 cup of coffee in the morning and about 3-4 colas during the day. Patient states “I eat healthy”.
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ROSConstitutional: Denies any weight changes. Denies weakness and fever. Denies changes in mental capacity. Denies changes in sleeping pattern. Skin: Denies redness, swelling, rashes, and itching. Denies hair loss or changes. Denies changes in nails. Denies sores and bruises. Head: Reports headaches every once in a while. Denies masses or growths. Denies head trauma.Eyes: Denies eye pain, redness, and drainage. Denies visual loss, double vision, and ptosis. Ears: Denies earaches, drainage, hearing loss, tinnitus, vertigo, and infection. Nose: Reports congestion prior to rhinoplasty surgery. Reports tenderness post-surgery. Denies drainage, and itching. Denies epistaxis.Throat: Denies throat soreness. Denies mouth pain, dryness, and oral ulcers. Denies taste problems. Neck: Denies pain or swellingRespiratory: Denies cough, shortness of breath, and wheezing. Denies hemoptysis and chest pain. Denies lung diseases and infections. Cardiovascular: Denies chest pain, palpitations and murmurs. Denies peripheral edema and claudication. No history of cardiac exams or conditions. Gastrointestinal: Denies diarrhea, constipation. Reports regular bowel movements daily. Deniesdifficulty swallowing, heartburn, and hematemesis. Reports RLQ abdominal pain. Reports no appetite today. Denies rectal bleeding, discharge and pain. Denies black, tarry stools. Reports nausea. Denies past GI disorders. Genitourinary: Denies frequency, urgency, burning, and pain during urination. Denies hematuria. Denies STDs. Reports being sexually active. Musculoskeletal: Denies fractures, sprains, and dislocations. Denies muscle soreness, cramps, stiffness, and twitching. Denies back pain. Denies muscle weakness and strength loss. Neurological: Denies changes in speech, memory, and attention. Denies numbness, weakness, visual problems. Psychiatric: Denies personality or behavior changes. Reports feeling anxious about abdominal pain. Denies depression. Denies alcohol and substance abuse. Denies suicidal thoughts. Endocrine: Denies excessive hunger and thirst. Denies fatigue, weight loss, and weight gain. Denies increase in urination.
OBJECTIVE (O)Vitals:BP: 120/70HR: 72 and regularRR: 16 and regularTemp: 98.6 orallyWeight: 140 lbs/63.5 kgHeight: 5’7” / 170.2cmBMI: 22
Physical Exam:
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General: The patient is well groomed and dressed appropriately. The patient is alert and oriented to person, place, time and situation. Answers questions appropriately. HEENT: Normocephalic. Hair distribution is full; hair is thick, with good luster. The patient’s scalpis smooth and supple; no lumps, interruptions, or other lesions are noted; the size and contour are normal, without apparent deformities, and there are no areas of tenderness. Temporal arteries soft, non-tender with no bruits. Auricles are symmetric, normally placed, and without deformities; no area of tenderness is noted. No ear lobe creases are present. Bilateral tympanic membranes are pearly gray with good cone of light, no erythema/bulging or retraction noted; bilateral, boney landmarks are visible. Eyes are symmetric in size, shape, color, and position. No scars, erythema, or growths are noted on lid or conjunctiva. Cornea is clear; pupils are equal, round, and reactive to light accommodation. Sclerae anicteric, conjunctiva pink/moist and without drainage. Nose shows evidence of recent surgery with swelling. Nares are patent bilaterally. Twenty-six teeth are present, with no cavities, and no active caries are noted; teeth are well-aligned and occlusion is symmetric with slight overbite. Gums are pale red and meet enamel margins of the teeth. Lips appear normal without ulcers or cracking. Buccal mucosa is pink, moist, and without ulcers or nodules. Hard palate is midline and moves symmetrically. Tongue appears normal without coating. Pharynx and tonsils appear normal without exudate. NECK: Supple. No cervical lymphadenopathy. No thyromegaly or jugular vein distention.RESPIRATORY: Respirations are unlabored, symmetrical chest wall expansion, no chest wall tenderness. Lung sounds clear. No cyanosis or clubbing of the fingers. CARDIOVASCULAR: The heart has a regular rate and rhythm, no gallops, rubs, or murmurs. S1 &S2 normal. No thrills or bruits are present. No edema of the lower extremities. MUSCULOSKELETAL: Active range of motion of the joints. No lumbar tenderness. There is paraspinal muscle spasm noted from T12 to L1.GASTROINTESTINAL: Abdomen is soft. There is tenderness in the RLQ on light palpation and severe pain on deep palpation. No masses can be palpated. Questionable rebound tenderness present. No pain on palpation of LLQ or LUQ; slight referred pain to the RLQ. There is tenderness on deep palpation in the RUQ at the tip of the 12th rib and a positive Chapman’s reflex at that point. The gallbladder is not palpable. The liver edge is palpable on deep inspiration; it is smooth and non-tender. There is slight referred pain to the RLQ on deep palpation. There is no rebound tenderness. Active bowel sounds in all quadrants. INTEGUMENTARY: Skin is pink, warm and dry. No rash present.NEUROLOGIC: Normal comprehension, fluency. Normal strength, bulk and tone in muscles of extremities. Alert and oriented. PROSTATE/RECTAL: The sacrococcygeal area is free of sinus tracts and the perianal area is free of rashes, excoriations, or other lesions; no external hemorrhoids are present; the anal sphincter has good tone; examination produces minimal discomfort; no internal hemorrhoids, irregularities or nodules are palpated; a small amount of soft stool is present in the rectum. The prostate is smooth, symmetric, and not enlarged; there are no nodules or areas of induration, and it is non-tender. Upon straining, no descending lesions are palpable.
Testing:
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1. CBC w/dif: WBC 17.9, RBC 5.3, Hemoglobin 15.2, Hematocrit 46.6%, MCV 85, MCH 32, MCHC 34.0%, Platelets 356, Bands 0%, Neutrophils 66%, Lymphocytes 28%, Eosinophils 2%, Monocytes 3%, Basophils 1%
2. CRP: 0.8 mg/dL3. Creatinine: 0.9 mg/dL4. Urinalysis, Routine: pH 6.5, Specific Gravity 1.020, Protein none detected, Bilirubin none
detected, Glucose none detected, Ketones none, Occult Blood none, RBCs/HPF 2/3, WBCs/HPF 0/1, Bacteria none, Epithelial Cells 0/1, Casts none, Nitrates negative, Urobilinogen negative
5. CT Abdomen: sigmoid colon, bladder, and ureters are normal in appearance. However, the cecum is enlarged and there is a small fluid collection
6. Ultrasound Abdomen: No hepatosplenomegaly noted, gallbladder within normal limits as is the common bile duct, no masses or abnormal fluid collections
ASSESSMENT (A)
DiagnosisNew problems: RLQ abdominal pain, nausea Primary Diagnosis: Acute appendicitis ICD-10 K35Diferentials:
1. Noninfective gastroenteritis and colitis, unspecified ICD-10 K52.92. Calculus of kidney ICD-10 N20.03. Diverticulitis of intestine, part unspecified, without perforation or abscess without
bleeding ICD-10 K57.92PLAN (P)
Treatment: Consult General Surgery for appendectomy. Patient to remain NPO. PRN analgesics and antiemetics for pain and nausea (Toradol and Zofran). Ensure peripheral IV is inserted. Initiate IV fluids and systemic antibiotics (defer choice in ABX to surgery).
Education: Patient educated on appendectomy surgery; made aware of risks and complications associated with surgery. Instructed to avoid strenuous activities until cleared by surgeon. Keep incisions clean and dry. Eat a bland, low-fat diet. Further education/questions directed to the surgery team.
Follow-up: as needed basis. Should follow-up with surgery team 2-3 weeks post-op. Follow up/call healthcare provider sooner with any of the following: swelling, pain, fluid, or redness in the incision that gets worse; fever of 100.4 or higher; abdominal pain that gets worse; severe diarrhea, bloating, or constipation; nausea or vomiting; trouble breathing or shortness of breath; leg swelling.
Patient verbalized understanding of the treatment plan and education provided.
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