SOAP NOTE: DIVERTICULITIS
Name: A. B.
Age: 68
Gender at Birth: Male
Gender Identity: Male
Allergies: NKDA
Current Medications:
Lisinopril 10 mg PO daily for HTN
Metformin 500 mg PO bi for Diabetes
Advil 800 mg BID for 10 days for pain
PMH:
Immunizations:
Preventive Care:
Surgical History: None
Family History: Mother: HTN, DM, Father: COPD
Social History: Currently residing with his wife in Miami Florida. He retired 3 years ago from Nursing profession, has 1 child, denied use the cigarette, no alcohol.
Sexual Orientation: Straight
Nutrition History:
Subjective Data:
Chief Complaint: Left lower abdominal pain, nausea and vomiting.
Symptom analysis/HPI:
The patient is a 68 year-old, came to the office C/O left lower abdominal pain, nausea and vomiting in the last 2 days ago and low-grade fever since today. Patient has history of Diabetes Mellitus Type II and hypertension that are controlled with oral medications, patient has been taken Advil 800 mg 1 tab PO BID for 10 days due to right shoulder pain.
Review of Systems (ROS)
CONSTITUTIONAL:
NEUROLOGIC: Patient denies anxiety, nervousness, Depression, Sadness, hallucinations.
HEENT: Denies corrective lenses, blurring, visual changes of any kind. Denies Ear pain, hearing loss, ringing in ears. Denies sinus problems, dysphagia, nose bleeds or discharge.
RESPIRATORY: Denies difficulty breathing wheezing, chest congestion, cough, and phlegm
CARDIOVASCULAR: Denies CP/SOB palpitations, chest pain. Regular rhythm
GASTROINTESTINAL: Patient has nausea, vomiting and abdominal pain.
GENITOURINARY: Denies changes in color or odor of urine.
MUSCULOSKELETAL: Denies back pain, joint swelling, stiffness. Pain in left shoulder.
SKIN: Denies any wounds, rashes, bruising, bleeding or skin discoloration, any changes in lesions.
Objective Data:
VITAL SIGNS: Weight: 150, Height 5.9, Temp 98.7, BP 126/76, Pulse 78, Respiration 20
GENERAL APPREARANCE: Patient AOx4 answer a question appropriately and well develop.
NEUROLOGIC: Denies dizziness, numbness or tingling in arm and legs. Normal sensory exam, deep tendon reflex symmetrical and equal bilaterally.
HEENT:
CARDIOVASCULAR: Heart rate and rhythm regular, normal S1 and S2, no murmurs, rubs, gallops or clicks. Heart location and apex normal. Carotid artery pulsations normal, no peripheral edema.
RESPIRATORY: Respiratory effort unremarkable. Respiratory rate and pattern normal, lungs clear to auscultation bilaterally, percussion of chest unremarkable.
GASTROINTESTINAL: Abdominal flat, soft non distended, bowel sounds present in all 4 quadrants. Abdominal tender to left lower quadrant with palpation.
MUSKULOSKELETAL: Normal inspection pain in left shoulder, normal station and stability.
INTEGUMENTARY:
ASSESSMENT:
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
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PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
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Pharmacological treatment:
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Non-Pharmacologic treatment:
Education (provide the most relevant ones tailored to your patient)
Follow-ups/Referrals
References
Ferri, F. (2017). Ferri's Clinical Advisor 2016: 5 Books in 1. [VitalSource Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9780323280471/
Mayo Clinic. (2019). Heart failure - Diagnosis and treatment - Mayo Clinic. Retrieved 11 October 2019, from https://www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148
McGraw-Hill Medical. (2019). Drugs | Access Medicine | McGraw-Hill Medical. Retrieved 11 October 2019, from https://accessmedicine.mhmedical.com/drugs.aspx?gbosID=426437
Reilly, J., Silverman, E., Shapiro, S. (2017). Chronic Obstructive Pulmonary Disease. Harrison's Principles of Internal Medicine, 19e. Retrieved from http://accessmedicine. mhmedical.com/content.aspx?bookid=1130&Sectionid=79745089.