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Student Name
Provide Information: Complete SOAP note #1
Date of patient encounter: 2/12/2015
Patient age and gender: 39-year-old, Female
DOB: 08/28/1975

SUBJECTIVE:
Chief Complaint: “I've been nauseous and throwing up for a few days. I've been cramping and
haven't been able to keep anything down. This isn't the first time that this has happen.”
History of Present Illness: 39-year-old African American female presents with complaints of
nausea vomiting and diffuse abdominal cramps for the last 2 days. The patient rated the pain
level 7 out of 10, 10 being the most intense an in the epigastric region. The patient states that
food is an aggravating agent, so she has been alleviating the vomiting herself by restricting her
intake. She states she has vomited several times within the past few days. The nausea and
cramping are consistent symptoms without any alleviation. The patient denies any diarrhea.
Past Medical History
 End-Stage Renal Disease- 585.6
 Systematic Lupus Erythema- 710.0
 Obesity- 278.0
 Hypertension- 401.9
 Anemia- 285.9
 Esophageal Ulcers- 530.2
 Gastric Ulcers- 531.90
 LMP: January 19th, 2015
 OB/Gyn Denies any abnormalities in the last Pap Smear

Surgical History
 AVF In Left Leg 2012 - Midtown Medical Center
 Parathyroidectomy 2011- Midtown Medical Center

Current Health Status:

1. Allergies: Codeine phosphate, Ondansetron HCl, Codeine and Penicillin
2. Tobacco: Denies Use
3. ETOH: Denies Use
4. Illegal Drugs: Denies Use.
5. Current Meds
 Calcitriol: 0.5mcg: capsules; 1 tablet PO daily for calcium replacement
 Aspirin: 81mg (baby aspirin) chewable tablet 1 PO daily
 Amlodipine (Norvasc): 5mg; 1 tab PO daily for hypertension
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 Levetiracetam (Keppra): 500mg; 1 tab PO Tuesday Thursday and Saturday

 Hydrocodone 10/325 (Norco 10/325); 1-tab q6 hours PRN for pain
 Calcium acetate (Phoslo): 667mg capsules; 2 capsules; 1,334mg PO TID with meals
 Simvastatin (Zocor): 10mg tablet; 20mg PO @ bedtime for hyperlipidemia
 Promethazine (Phenergan): 25mg tablet; 25mg PO TID PRN for nausea
 Alprazolam (Xanax): 1mg; 1 tablet PO bid PRN for anxiety

6. Injuries: Denies
7. Environmental hazards: Patient denies being exposed to any environmental hazards at
home or work
8. Screening tests: Patient has yearly pap smear in breast exam perform at gyn office patient
reports performing SBE at out at home as well
9. Safety measures: Patient reports she wears her seat belt while driving and does not text or
talk on the phone. Patient reports she has a fire detector throughout her home
10. Immunizations: patient reports they are all current patient states she received her yearly
flu shot
11. Exercise and leisure: Patient reports she enjoys spending time with her family and
boyfriend
12. Sleep: Patient reports she sleeps approximately 5 to 6 hours a night and reports some
difficulties falling asleep lately due to nausea.
13. Diet: 24-hour recall
 Dinner 2/11/2015 a few bites of chicken in water
 Breakfast some grape juice
 Lunch nothing, "I haven't been able to eat."

Family History:
Patient reports her mother is 59 years old and alive with history of hypertension type 2 diabetes
and obesity. Father is 57 years old and alive with a history of Hypertension. Patient denies any
knowledge of chronic illness in either parents. Patient reports Hypertension and Cardiac Issues in
both paternal grandparents and Type 2 Diabetes in the grandmother. The paternal grandfather
passed after a stroke at the age of 71 and the grandmother's cause was cardiac related. The
paternal grandfather passed of a heart attack and a great grandmother of unknown cause; most
likely age related. The patient reports of hypertension and obesity in both maternal and
grandparents. Maternal grandfather passed away from unknown cause at 78 years old and the
grandmother caused from pancreatic cancer at 76 years old. Maternal great grandfather passed
away from prostate cancer and great grandmother of natural causes due to age. Patient reports
she has 4 children: 3 daughters 23, 17, and 16 years old and 21-year-old son. She has a 5-year-
old granddaughter and a 3-year-old grandson.
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Social History
Patient reports she is in a monogamous relationship for 5 years in denies using condoms.
Recently located to LaGrange due to her boyfriend’s job in Atlanta. She has 4 children from a
prior relationship and 2 grandchildren. She is also the main provider in support of her family.
She has assumed the majority of responsibilities for the grandchildren. Her father recently
relocated to be closer to the family. Somewhat a strayed from her mother. Patient reports she has
only had a few sexual partners. Patient denies any STD's or any risk factors for HIV. Patient
denies any recreational drug use.

Erickson: Generativity vs. Stagnation

The patient stating, she enjoys the company of her family and boyfriend shows she is the
generativity stage. This is further evidence by the supportive behavior of the younger generations
in her family.
Review of Systems:
 General: Patient denies having chills. Denies any sudden weight loss or gain. Denies
having any unexplained bruising or bleeding. Denies any unexplained sleep disturbances.
 Head and Neck: Denies any head injuries or headaches. Denies any pain, swelling, or
stiffness.
 Eyes: Denies the need for corrective lenses. Denies any complications of tearing.
 Ears: Denies any ear pain or discharge. Patient issues Q-tips.
 Nose and Sinuses: Denies any sinus complications or epistaxis.
 Mouth and Throat: History of esophageal ulcers. Denies sore throat. Denies any bleeding
or swelling of the gums.
 Skin, Hair, and Nails: Denies any rashes or lesions. Denies any changes to hair and nails.
 Chest and Lung: Denies shortness of breath, dyspnea, wheezing, or coughing. Denies any
pain related to respiration. Denies any hemoptysis, night sweats or exposure to
tuberculosis.
 Cardiovascular: Patient states some difficulty performing daily activities. Denies any
chest pain, dyspnea, palpitations, and orthopnea.
 Breast: No history of lumps or tumors in the breast area denies tenderness discharge or
pain
 Musculoskeletal: mild weakness on dialysis days post treatment. Denies any other pain
weakness joint stiffness or other complaints
 Peripheral vasculature: denies any pain tenderness discoloration temperature change
swelling or claudication in extremities
 Lymphatic: no known lymph node enlargement or tenderness reported
 Gastrointestinal: history of peptic ulcers history nausea and vomiting currently
experiencing nausea vomiting and abdominal cramps denies any hematemesis denies any
diarrhea or Constipation denies blood in stool denies any change in the color or contents
of stools reported bowel movements as normal
 Endocrine: denies thyroid enlargement or tenderness parathyroidectomy in 2011
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 Genitourinary: denies a history of sexually transmitted infection denies pain discharge

itching or genital lesions denies urgency, frequency, hesitancy, dysuria flank, or super
pubic pain. Denies nocturia, hematuria, polyurea or stress incontinence
 Neurologic: denies syncope seizure or tremors denies any numbness or tingling
throughout the body
 Mental status in psychiatric: denies any sleep disturbances or change in mood objective

OBJECTIVE

Vital Signs:

 Pulse: 64
 BP: 137/84 on right arm with patient sitting with large adult cuff
 RR: 18 breaths per minute
 02sat: 97% on room air
 Temp: 99.5F orally
 HT: 5 ft 5 inches
 WT: 191 lbs.
 BMI: 31.8 patient is morbidly obese

General Appearance statement: 39-year-old African American female patient is obese, and
well-groomed patient is slightly guarding the abdomen and leaning forward while sitting.

Physical Exam:
 Skin, Hair, and Nails: Skin is soft, dry, without tenting. Nail beds pink without clubbing.
Nails are uniform in thickness, smooth, firmly adhered to nail bed, <2 seconds capillary
refill. Hair is shiny with normal thickness and evenly distributed.
 Head and Neck: Head erect and midline. Scalp freely movable without lesions or
tenderness. Scalp is dry. Facial features and expression symmetrical when talking,
accessing CN VII. No bruit present bilaterally in temporal arteries and palpable 3+
bilaterally. No tenderness or palpable lymph nodes noted. Carotid pulse palpable 3+
bilaterally. No carotid bruit auscultated bilaterally. ROM of neck and shoulders without
pain or difficulty, assessed CN XI during ROM.
 EENT: Eye brows and lashes evenly distributed. No tearing or crusting. No redness or
jaundice. Conjunctiva pink and moist. Pupils graded as 4mm. Pupils react equally to light
accommodation, assessing CN III. Eyes smoothly transition to the six cardinal fields of
gaze without deviation, assessing CN II, IV, and VI. No nystagmus. No abnormalities in
red reflex. Peripheral vision present bilaterally. Central visual acuity; 20/20 bilaterally
and capable of reading small print, assessing CN II. Auricles in proper alignment. No
lesions or masses. No cerumen bilaterally. Tympanic membranes gray. No exudates or
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redness noted. Positive Whisper test bilaterally; assessing CN VIII. Nares patent
bilaterally. Mucosa is pink and moist. No polyps, drainage, or septal deviation. No sinus
tenderness noted. Red glow present upon trans-illumination of sinus. Properly identify
the smell of alcohol, assessing CN I. Oral cavity is pink, moist, and has no lesions. No
dental appliances to remove good; dental health with strong bite; assessing CN V.
Tongue is midline without lesions. Uvula is midline. Uvula rises and is without deviation
when saying “ah,” assessing CN X. Gag reflex intact. No redness, swelling, or legions in
pharynx. Can identify the taste of sugar, assessing CN IX.
 Chest and lung: No distress or labored breathing. No chest pain. No tenderness upon
palpation. No CVA tenderness. Resonant percussion throughout. Tactile fremitus
symmetrically. Auscultated clear lung sounds bilaterally. No adventitious sounds noted.
 Cardiovascular: S1 and S2 heard, no S3 or S4. No gallops, rubs, or murmurs. Pulses
present radial 3+ and pedal 3+. Capillary refill<2 bilaterally on upper and lower
extremities. No palpitations or syncope noted. Allen’s test < 3 seconds. Pitting edema 2+
bilaterally on lower extremities.
 Breast: Full exam deferred. No complaints of pain or swelling. SBE explained.
 Gastrointestinal: Abdomen is round, soft, and symmetrical. Umbilicus is midline. No
rashes, masses, or lesions. No pulsations visible. Bowel sounds present x 4. Tympany
predominant over 4 quads. Abdomen is soft with tenderness upon palpation. Liver not
palpable. Spleen not palpable. No rebound tenderness. Negative McBurney’s sign.
Negative Murphy’s sign. No ascites noted. Repots vomiting at least 3 times today.
 Musculoskeletal: No weakness, pain or crepitus noted. Full ROM present in all joints. No
pain noted upon ROM of joints. No decreased muscle strength when opposing force
applied to ROM. Normal spinal curvature. Deep tendon reflex 2+ obtained and
symmetrical to patella abd biceps bilaterally. Babinski reflex negative. Flexion and
extension maintained against resistance and without tenderness.
 Lymphatic: No palpable lymph node.
 Genitalia: Deferred.
 Neurologic: Awake, alert, and oriented x 3. No slurred speech, vertigo. Provides
appropriate responses. Patient can follow directions. Cranial nerves 1-XII intact. Good
coordination and smooth, rapid alternating movement. Negative Romberg. Positively
differentiates dull and sharp sensations.

Present labs/diagnostic tests:

 No lab or diagnostic tests available

ASSESSMENT:
This is a 39-year-old female with a history of end-stage renal disease, hypertension, and gastric
ulcers with acute abdominal pain, nausea/vomiting. Exams elicit tenderness with palpitation.
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Differential Diagnoses:
1. Noninfectious Gastroenteritis-558
2. Gastritis-535.00
3. Gastric Ulcer-531.90
4. Pancreatitis-577.0
5. Diverticulitis-562.11

Final Diagnosis w/ICD code and highlight data that support decision:
1. Noninfectious Gastrenteritis-558- Patient stated, “this isn’t the first time this has happen.”
Relieved nausea after vomiting, vomiting immediately postprandial, pain relieved by the
absence of food, abdominal cramping and fever.

Chronic Diagnosis:
2. End-Stage Renal Disease-585.6-Controlled
3. Systemic Lupus Eryematous- 710.0-Controlled
4. Obesity-278.0
5. Hypertension-401.9- Controlled
6. Anemia-285.9-Controlled

Plan: