see attached, same as last one need last 2 sections completed. see starred items that must be included.files (1)MSN_SOAP_CarrieFisher.docxMSN_SOAP_CarrieFisher.docx
Name: Cassie Fisher
Pt. Encounter Number: 1
Date: 9/20/23
Age: 52
Sex: Female
SUBJECTIVE
CC:
??pain in belly that won??t let up?
HPI:
Patient is a 52 yo female who presents to the office today with c/o abdominal pain. She states the pain began about 1 week ago. Reports that the pain began gradually, initially occurring a few times a day and lasting 1-2 hours then slowly resolving however the pain is now constant. She states the pain is in right upper abdomen under the rib cage and radiates to her back. Pain is described as sharp and stabbing. She states the pain became worse 2 days ago when she vomited. She does not identify any alleviating factors. She states she has been taking ibuprofen as needed for the pain since it started, which initially was helpful but is no longer relieving the pain. She states the pain began as a 3 out of 10 but now stays around a 7 out of 10. Associated symptoms include nausea, one episode of vomiting, decreased appetite. She has never had these symptoms before and has not sought any other treatment or had any diagnostic testing.
Medications:
Simvastatin20mg once daily for hyperlipidemia
Glyburide 5mg once daily for diabetes
Metformin 1000mg twice daily for diabetes
Lithium 300mg once daily for bipolar
Quetiapine 400mg twice daily for bipolar
Allergies:
NKDA
Medication Intolerances: none noted
Past Medical History:
Hypercholesterolemia
Diabetes
Uterine fibroids
Past Psychiatric History:
Bipolar
Hospitalizations/Surgeries
Partial hysterectomy secondary to fibroids
Childbirth x 2
Preventive
Immunizations are UTD
Last PAP 2022 normal.
Family History
Father deceased lung cancer
Mother alive diabetes, HTN
Social History
Pt is a high school graduate. Works as a professional actor and often travels. Lives alone and feels safe in her home. Divorced x2. She is not in a relationship currently and is not sexually active. Smokes ½ -1 ppd x 30 years. Has made multiple unsuccessful attempts at quitting. Denies current alcohol use, states she has been sober for 12 years. Denies current drug use, reports no use in 15 years.
ROS Student to ask each of these questions to the patient: ??Have you had any?¦..?
General
Denies recent weight change, fever/chills and fatigue.
Cardiovascular
Denies CP, palpitations or edema
Skin
Denies rash, discoloration.
Respiratory
Denies cough or SOB
Eyes
Denies vision changes.
Gastrointestinal
? pain radiating to back. ??, ???. Denies diarrhea or constipation ??? appetite. Denies blood in stool
Ears
Denies complaints
Genitourinary/Gynecological
Denies urinary complaints
Nose/Mouth/Throat
Denies complaints
Musculoskeletal
Denies complaints
Breast
Performs SBE, no concerning findings.
Neurological
Denies syncope, weakness
Heme/Lymph/Endo
Denies complaints
Psychiatric
??, compliant with medications, denies current depression, denies SI.
OBJECTIVE
Weight BMI
Temp 37.1
BP 138/84
Height
Pulse 92
Resp 16 O2 Sat 97%
General Appearance
Pt is alert and oriented and in no acute distress. Interacting appropriately.
Skin
Warm and dry. No rash or jaundice.
HEENT
Head normocephalic. No scleral icterus.
Oropharynx normal without erythema or exudate.
Mucus membranes moist.
Dentition intact.
Cardiovascular
Heart with regular rate and rhythm. Normal S1, S2 without murmur, gallop or rub. Normal pulses, no edema.
Respiratory
Lungs clear throughout. Normal effort.
Gastrointestinal
Abdomen soft. ??? guarding RUQ. ??? severe tenderness RUQ and epigastric area. No rebound.. Active bowel sounds.
????s sign
No hepatosplenomegaly.
Breast
Deferred
Genitourinary
No CVA tenderness
Musculoskeletal
Normal ROM and gait observed.
Neurological
Alert and oriented x3.No focal deficits.
Psychiatric
Appropriately dressed, interacting appropriately.
Lab Tests
Abdominal Ultrasound:Spleen and pancreas with normal appearance. No focal liver lesion. Gallbladder normal with no gall stones. No intra or extra-hepatic duct dilatation. Common bile duct measures 4mm. Kidneys appear normal. Right kidney 11.7cm, left kidney 10.2 cm. Impression: Normal general abdominal ultrasound.
Amylase 50
CBC with differential
·
HGB 12.2
·
HCT 38.3
·
MCV 90
·
MCH 28.5
·
MCHC 32.1
·
RDW 13.1
·
PLT 225
·
Neutrophils 50
·
Lymphs 35
·
Monocytes 13
·
Basos 0
·
Neutrophils (absolute) 3.3
·
Lymphs (absolute) 2.3
·
Monocytes (absolute) 0.8
·
Eos(absolute) 0.1
·
Basos (absolute) 0
·
Immature granulocytes 0
·
Immature Grans (absolute) 0
·
NRBC 0
CMP
·
Glucose 95
·
BUN 20
·
Creatinine 1.0
·
eGFR if non African Amer 90
·
eGFR if African Amer 105
·
BUN/Create ratio 20
·
Sodium 140
·
Potassium 4.0
·
Chloride 99
·
Carbon Dioxide, Total 25
·
Protein, total7.0
·
Albumin 4.5
·
Globulin, total 2.5
·
A/G ratio 1.8
·
Bilirubin, total 1.0
·
Alkaline Phosphatase 40
·
AST(SGOT) 39
·
ALT(SGPT) 42
·
Carbon Dioxide, total 25
·
Calcium 9.0
Assessment
· Include at least three differential diagnoses
· Provide rationale for each differential diagnosis
· Final diagnosis—******biliary colic******
· Pathophysiology of primary and rationale for choosing as final
Plan
· Medications *****antiemetics-zofran,reglan, try different NSAID ketorolac********
· Non-pharmacological recommendations
· Diagnostic tests
· Patient education
· Culture considerations
· Health promotion *********low fat diet************
· Referrals***********GI***************
· Follow up***********as needed w PCP************
MSN_SOAP_CarrieFisher.docx
Name: Cassie Fisher
Pt. Encounter Number: 1
Date: 9/20/23
Age: 52
Sex: Female
SUBJECTIVE
CC:
??pain in belly that won??t let up?
HPI:
Patient is a 52 yo female who presents to the office today with c/o abdominal pain. She states the pain began about 1 week ago. Reports that the pain began gradually, initially occurring a few times a day and lasting 1-2 hours then slowly resolving however the pain is now constant. She states the pain is in right upper abdomen under the rib cage and radiates to her back. Pain is described as sharp and stabbing. She states the pain became worse 2 days ago when she vomited. She does not identify any alleviating factors. She states she has been taking ibuprofen as needed for the pain since it started, which initially was helpful but is no longer relieving the pain. She states the pain began as a 3 out of 10 but now stays around a 7 out of 10. Associated symptoms include nausea, one episode of vomiting, decreased appetite. She has never had these symptoms before and has not sought any other treatment or had any diagnostic testing.
Medications:
Simvastatin20mg once daily for hyperlipidemia
Glyburide 5mg once daily for diabetes
Metformin 1000mg twice daily for diabetes
Lithium 300mg once daily for bipolar
Quetiapine 400mg twice daily for bipolar
Allergies:
NKDA
Medication Intolerances: none noted
Past Medical History:
Hypercholesterolemia
Diabetes
Uterine fibroids
Past Psychiatric History:
Bipolar
Hospitalizations/Surgeries
Partial hysterectomy secondary to fibroids
Childbirth x 2
Preventive
Immunizations are UTD
Last PAP 2022 normal.
Family History
Father deceased lung cancer
Mother alive diabetes, HTN
Social History
Pt is a high school graduate. Works as a professional actor and often travels. Lives alone and feels safe in her home. Divorced x2. She is not in a relationship currently and is not sexually active. Smokes ½ -1 ppd x 30 years. Has made multiple unsuccessful attempts at quitting. Denies current alcohol use, states she has been sober for 12 years. Denies current drug use, reports no use in 15 years.
ROS Student to ask each of these questions to the patient: ??Have you had any?¦..?
General
Denies recent weight change, fever/chills and fatigue.
Cardiovascular
Denies CP, palpitations or edema
Skin
Denies rash, discoloration.
Respiratory
Denies cough or SOB
Eyes
Denies vision changes.
Gastrointestinal
? pain radiating to back. ??, ???. Denies diarrhea or constipation ??? appetite. Denies blood in stool
Ears
Denies complaints
Genitourinary/Gynecological
Denies urinary complaints
Nose/Mouth/Throat
Denies complaints
Musculoskeletal
Denies complaints
Breast
Performs SBE, no concerning findings.
Neurological
Denies syncope, weakness
Heme/Lymph/Endo
Denies complaints
Psychiatric
??, compliant with medications, denies current depression, denies SI.
OBJECTIVE
Weight BMI
Temp 37.1
BP 138/84
Height
Pulse 92
Resp 16 O2 Sat 97%
General Appearance
Pt is alert and oriented and in no acute distress. Interacting appropriately.
Skin
Warm and dry. No rash or jaundice.
HEENT
Head normocephalic. No scleral icterus.
Oropharynx normal without erythema or exudate.
Mucus membranes moist.
Dentition intact.
Cardiovascular
Heart with regular rate and rhythm. Normal S1, S2 without murmur, gallop or rub. Normal pulses, no edema.
Respiratory
Lungs clear throughout. Normal effort.
Gastrointestinal
Abdomen soft. ??? guarding RUQ. ??? severe tenderness RUQ and epigastric area. No rebound.. Active bowel sounds.
????s sign
No hepatosplenomegaly.
Breast
Deferred
Genitourinary
No CVA tenderness
Musculoskeletal
Normal ROM and gait observed.
Neurological
Alert and oriented x3.No focal deficits.
Psychiatric
Appropriately dressed, interacting appropriately.
Lab Tests
Abdominal Ultrasound:Spleen and pancreas with normal appearance. No focal liver lesion. Gallbladder normal with no gall stones. No intra or extra-hepatic duct dilatation. Common bile duct measures 4mm. Kidneys appear normal. Right kidney 11.7cm, left kidney 10.2 cm. Impression: Normal general abdominal ultrasound.
Amylase 50
CBC with differential
·
HGB 12.2
·
HCT 38.3
·
MCV 90
·
MCH 28.5
·
MCHC 32.1
·
RDW 13.1
·
PLT 225
·
Neutrophils 50
·
Lymphs 35
·
Monocytes 13
·
Basos 0
·
Neutrophils (absolute) 3.3
·
Lymphs (absolute) 2.3
·
Monocytes (absolute) 0.8
·
Eos(absolute) 0.1
·
Basos (absolute) 0
·
Immature granulocytes 0
·
Immature Grans (absolute) 0
·
NRBC 0
CMP
·
Glucose 95
·
BUN 20
·
Creatinine 1.0
·
eGFR if non African Amer 90
·
eGFR if African Amer 105
·
BUN/Create ratio 20
·
Sodium 140
·
Potassium 4.0
·
Chloride 99
·
Carbon Dioxide, Total 25
·
Protein, total7.0
·
Albumin 4.5
·
Globulin, total 2.5
·
A/G ratio 1.8
·
Bilirubin, total 1.0
·
Alkaline Phosphatase 40
·
AST(SGOT) 39
·
ALT(SGPT) 42
·
Carbon Dioxide, total 25
·
Calcium 9.0
Assessment
· Include at least three differential diagnoses
· Provide rationale for each differential diagnosis
· Final diagnosis—******biliary colic******
· Pathophysiology of primary and rationale for choosing as final
Plan
· Medications *****antiemetics-zofran,reglan, try different NSAID ketorolac********
· Non-pharmacological recommendations
· Diagnostic tests
· Patient education
· Culture considerations
· Health promotion *********low fat diet************
· Referrals***********GI***************
· Follow up***********as needed w PCP************
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