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(SOAP NOTE) NR511 WEEK 4 M. MILLER Patrick Smith 42 YO(CC Pain in back and abdomen)
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- Chamberlain College Nursing
(SOAP NOTE) NR511 WEEK 4 M. MILLER Patrick Smith 42 YO(CC Pain in back and abdomen)
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(SOAP NOTE) NR511 WEEK 4 M. MILLER Patrick Smith 42 YO(CCPain in back and abdomen)
M. Miller SOAP WEEK 4
Patrick Smith Age 42
Subjective
Chief complaint: “I am in a lot of pain in my back and abdomen” History of
present illness (HPI):
O: Onset- 5 am
L: Location—initially pain begin on the side of his back; and now there is also pain in his stomach
D: Duration-intermittent pain that comes in waves
C: Characteristics/Associated symptoms- throbbing, feels nauseated, urinary frequency, sweaty, pain that and at times shoots
down to the groin
A: Aggravating factors -sitting in the office
R: relieving factors- nothing
T: Treatments- used Tums and they were not effective, nor was position changes
S: Severity- rated 8/10
Past Medical History- NKDA. Immunizations UTD. Describes health as good. Has hay fever and psoriasis,
medication which was given at last visit worked, not using at this time. No previous back injuries. No daily
medications. No herbal medication use. Had his appendix out at age 10. Previous hospitalization for broken
leg requiring traction at age 8.
Family History- Parents are deceased. Mother died at age 51 from a brain tumor and father died age 53
leukemia. Has one brother in good health.
Social History- Married, has four children. Lives with his immediate family and in-laws. Works full time as a
plumber. Work has been so busy no time lately for regular exercise. Smokes cigarettes, a pack a day. No
ETOH or illicit drug use. Sleeps 5-6 hours a night.
Review of Systems:
Neurologic: no report of further headaches, denies dizziness
Head/Eyes/Ears/Nose/Mouth/Throat: No report of nasal congestion, or discharge, denies lymph node
enlargement
Integumentary: not reviewed
Cardiovascular: denies palpitations
Respiratory: No report of wheezing or shortness of breath with rest
Genitourinary: not reviewed
Gastrointestinal: No reports of heartburn, or indigestion, endorses nausea
Musculoskeletal: not reviewed
Hematologic: not reviewed
Endocrine: not reviewed
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, Objective
VS T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%. 5 feet 9 inches weight: 195 pounds BMI 28.8
Urinalysis: Positive WBCs, Small blood. Trace protein, pH 7.0 specific gravity 1.030, negative nitrites,
negative ketones, negative glucose
CBC: WBC 6000 mm3 RBC 5 million Hbg 15g Hct 46% MCV 90 fL MCHC 35 g/dL
Ultrasound report: 5mm smooth round calculus is noted at the junction of the ureter and the bladder
Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution throughout scalp.
Sclera clear, conjunctiva white. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus
nontender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally.
Teeth in good repair, no cavities noted. Neck supple.
No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1
and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen
appears slightly distended, symmetric with no visible masses. RLQ scar noted. Decreased bowel sounds
noted. No vascular sounds. Tympany noted in all four quadrants on percussion. Abdomen is soft, no
organomegaly, no masses or tenderness. Positive CVAT on right side.
Assessment:
Urolithiasis (ICD 10: N21.9)- Frassetto and Kohlstadt (2011) report that plaques are composed of calcium
phosphate/apatite deposits, localized to the basement membrane of the thin loop of Henle and extending
into the papillary interstitium. When these plaques form, they erode through the urothelium and constitute a
stable, anchored surface on which calcium oxalate crystals can nucleate and grow as attached stones (Frassetto
& Kohlstadt, 2011). This patient is believed to have nephrolithiasis as he complains of acute severe flank pain,
nausea, urinary frequency, groin pain, and costovertebral angle tenderness. In addition, the ultrasonographer
has stated the patient has a 5mm stone which is present at the junction of the ureter and the bladder. The
location of the stone is known as ureterovesical junction. Lastly, the urinalysis identified hematuria to further
support the diagnosis.
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