6430-WEEK 2 SOAP NOTE

Name: Hyunsoo Ellis

Pt. Encounter Number

Date:

Age: 45 years

Sex: Male

SUBJECTIVE

CC:

The patient has an acute lower back pain

HPI

The patient reports low back pain which begun three weeks ago, he started experiencing pain at night, fever, and unexplained weight loss. The pain begun at the lower back, the pain aggravates while sitting than when in motion and it is dominant during the day than at night while sleeping. Pain alleviate when the patient used painkillers and when he is standing or lying. The patient has no record of recent illness, the patient works in an office; he does not have history of previous back injury or back surgery.

Medication:

Aspirin

muscle relaxants

Allergies: Coldness, dust

Medication intolerance: none

Major illness/Major traumas: none

Hospitalization/Surgery: Patient has knee surgery due to accident

The patient reports no cases of diabetes, HTN, Peptic ulcer, asthma, lung disease, heart disease cancer, and TB and kidney problems. He has had typhoid problems and no psychiatric diagnosis

Family History:

The patient reports that there is no one in his family who has been diagnosed with any medical or psychiatric disease. However, his father was diagnosed with lung disease ten years ago and his mother has been suffering from TB for a long time.

Social History:

The patient has MBA degree; he works as a business manager in a production firm and lives with his wife and two children. The patient takes alcohol, he does not engage in extra marital activities, does not engage in any dangerous activities such as biking, and sky diving and skating.

ROS

General:

The patient has lost weight, reports fatigue mainly after work, fever and night sweats.

Cardiovascular:

The patient reports no chest pain, the heart rate is normal (no palpitations), He experiences PND but not frequently and no signs of edema

Skin

The patient does not have rashes, bleeding or any skin discoloration. The patient has few changes in lesions and moles.

Respiratory

The patient does not cough but sneezes at night and very early in the morning, he has no record of TH but received treatment of pneumonia some years back

Eyes

The patient has clear visualization and does not experience visual changes of any kind. His corrective lenses are good.

Gastrointestinal

The patient experiences abdominal pains occasionally and has cases of constipation. The patient has no history on hemorrhoids and hepatitis, he has no eating disorders and does not have black or tarry stool.

Ears

The patient has healthy ears with no pain, no hearing loss and he does not experience any ringing in ears or discharge.

Gynecological

The patient experiences frequent urgency to urinate with urine changing color periodically, the patient does not use any contraception (wife does), has one sexual partner, no STDs

Mouth/Nose/Throat

The patient does not have any sinus problem, no dysphagia, experiences nose bleeds (occasionally), has tooth cavity, no hoarseness and throat pain

Musculoskeletal

The patient experience back pain, has no joint swelling, he experiences stiffness and pain in the neck, has no fractured hx and no osteoporosis

Breast

There are no changes in the patient’s breast

Neurological

The patient has no prior cases of syncope, no seizures, no record of transient paralysis, experiences weakness sometimes, and does not experience incidences of black-out

Heme/Lymph/Endo

Patient HIV status is negative, he has no bruises, no blood transfusion record, experiences night sweats, has no swollen glands, he reports reduced thirst. The patient has increased hunger and cold intolerance (sneezes in coldness)

Psychiatric

The patient has suffered depression in the past, has not anxiety disorder, experiences sleeping difficulties, has never had suicidal ideation/attempt and no previous hx

OBJECTIVE

Weight 68.7 kg BMI 23.77

Temp 97.8 °F

BP 148/84 (seated, right arm)

Height 1.70 m

Pulse 60 regular and rhythm

Resp 12

General appearance

The patient appears healthy with no distress. He is alert and oriented, keen and answers questions appropriately. The patient looked moody at first but later jovial.

Skin

The skin is brown, hairy, dry and clean. The patient has no rashes or lesions visible

HEENT

The head is normocephalic and atraumatic, the patient is baldheaded no depressions, the visual acuity is intact, EOM are intact, PEARLA, no nystagmus. Ears are pinna, tragus and earn canal is tender. The tympanic membrane is normal. The nasal mucosa is pink and moist, the nasal septum of the patient is midline and the tongue is normal, no buccal nodules, pharynx is normal. The patient shows no adenopathy

Cardiovascular

Normal S1 and S2 with regular rate and rhythm. There are no extra sounds or murmurs, capillary refill two secs, 3 and pulse throughout. No presence of edema

Respiratory

The patient has chest symmetric wall, has a regular respiration, the lungs are clear to auscultation bilaterally

Gastrointestinal

Shape of the abdomen rounded, smooth with no lesions, distention moderate, the stomach has visible peristalsis

Breast

There is no discoloration of the skin around the breast

Genitourinary

Male: Both testes are palpable, no masses or lesions, no hernia, and no urethral discharge. Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, non-tender, and free from nodules, is of normal size, and sphincter tone is firm.

Musculoskeletal

The patients shows full range of movement as he moves around the room during examination.

Neurological

The patient’s speech is clear, the tone is normal and his posture is erect. The patient is balanced, stable and gait is normal

Psychiatric

The patient is alert and oriented, dress in clean slacks and white shirt and a coat. The patient maintains eye contact, his responses are soft and clear and he answers questions appropriately.

Lab tests

Urinalysis- pending

Urine culture-pending

Wet prep- pending

Special tests

Diagnosis

PLAN including education

· Include at least three differential tests

· Final Diagnosis

· Evidence for final diagnosis should be documented in your subjective and objective exams.

Plan

· Further testing

· Medication

· Education

· Non medication treatment

· Follow up