Soap Note for A man with Bizarre Behaviour 

MEDICAL DOCUMENTATION MEDICAL DOCUMENTATION MEDICAL DOCUMENTATION The medial documentation referred to as the Subjective, Objective, Assessment, and Plan Note, or SOAP Note, is a method by which health care providers communicate with one another. The purpose is to ensure that all parties, whether they be primary care providers or otherwise, are able to document their patient interactions in a structured and organized way. It also serves as a general cognitive framework for physicians to follow as they assess a patient. The documentation includes appointment scheduling, patient check-in and examination, documentation of notes, patient check-out, rescheduling, and medical billing. The origin of this documentation is the problem-oriented medical record (POMR) which was developed nearly fifty years ago by Lawrence Weed, MD. The original intention was to allow physicians to approach complex patients with multiple problems in an organized way; however, it is now widely integrated into the healthcare community in a way which allow for inter-disciplinary communication with regards to patient progress. It is not limited to communities within a clinic or hospital as well given that pre-hospital care providers, such as emergency technicians, use the same way to communicate when bringing a patient to an emergency clinician. Due to its efficiency and simplicity, the use of SOAP Notes now ranges from physicians to veterinarians. SUBJECTIVE: The subjective contains all of the information which was obtained from the patient themselves. It describes the clinician’s impressions of the patient and should include descriptions of the patient’s interactions, feelings, and performance. There are many items which are included in this portion of the examination, all of which are denoted below. Chief Complaint (CC): The chief complaint, or the main reason which the patient is visiting a department, is listed here. The identifying information for the patient should be mentioned here including name, age, sex, ethnicity, date of birth (DOB). History of Present Illness (HPI): The history of present illness is a succinct summary of the information which the provider has (most likely, verbally) obtained from the patient. Social History (SocHx): The social history contains various details of the current life of the patient including relationship with alcohol, relationship with tobacco, relationship with illicit drugs, occupation, exercise routine, immunization, and whom they live with. In the instance that the patient partakes in alcohol, tobacco, or illicit drugs, it is imperative to note the type that they partake in and their current usage (e.g. two glasses of wine with dinner four times a week). Past Medical History (PMHx): The past medical history includes relevant diagnoses which the patient has had over the course of their lifetime and the year(s) which they were inflicted with it. Past Surgical History (PSHx): The past surgical history includes surgeries which the patient has had over the course of their lifetime and the year(s) which they occurred. Medications: A list of the medications which the patient is currently taking including dosage and frequency. This should include any herbal supplements and vitamins. 1 MEDICAL TERMINOLOGY Allergies: A list of the current allergies which the patient is inflicted with. This should include any environmental allergens. Family History (FHx): The family history includes a list of the patient’s immediate family members (father, mother, and siblings) as well as their current health status. If an extended family member has a relevant diagnosis, this should be included as well. Review of Systems (ROS): The review of systems is a succinct summary of the information which the provider has (most likely, verbally) obtained from the patient. For the purpose of this assignment, you are only required to list three systems, one of which must be relevant to the chief complaint. OBJECTIVE: The objective portion contains all of the information which was obtained from a physician examination of the patient by the provider. It contains measurable outcomes about the patient’s performance, including test scores, percentages for any goals worked on, and quantitative information. Vital Signs: The vital signs are a list of the current vital signs a patient has presented with. It includes blood pressure (BP), pulse rate (PR), temperature (T), respiration (R), height (Ht), weight (Wt), Body Mass Index (BMI) and last menstrual period (LMP). Objective Examination: A thorough examination of the body, with emphasis on the system that is relevant to the chief complaint, follows the vital signs. For the purpose of this assignment, you are only required to list three systems, one of which must be relevant to the chief complaint. ASSESSMENT: The assessment portion contains all of the information which was obtained from a physician examination of the patient by the provider. It contains an analysis and interpretation of the session as well as any notes on the progress of the patient. It is important to include the International Classifications of Diseases (ICD) code in this section. For the purposes of this assignment, the identification of the ICD code is mandatory; however, points will not be deducted for an incorrect answer. PLAN: The assessment portion contains all of the information which was obtained from a physician examination of the patient by the provider. It contains an outline of next steps in treatment of the patient include all activities, objectives, or reinforcements. For the purposes of this assignment, the inclusion of medications and laboratories is not mandatory; however, a student must include their electronic signature with a title of their choice. FORMATTING REQUIREMENTS The purpose of this assignment is to expose the learner to a type of document which is an integral part of communication within the medical community. This assignment is composed of four main components: [1] Subjective, [2] Objective, [3] Assessment, and [4] Plan. The assignment must be completed using a standardized patient provided by the instructor; therefore, a fictitious patient from any other source will not be accepted. The assignment must be submitted to the instructor by the indicated deadline in an appropriate format (e.g. .doc, .docx, .pdf) with proper formatting. This includes: [1] Times New Roman, [2] 12 Point Font, [3] Double Spaced, and [4] 1” Margins. The failure to meet this deadline will result in no points being awarded. There is no minimum page requirement. It should be noted that this assignment is not a formal written paper; therefore, the inclusion of a title page, introduction, body paragraphs, conclusion and references page is not required. 2 MEDICAL DOCUMENTATION GRADING RUBRIC 1 Points 3 Points SUBJECTIVE Chief Complaint 5 Points _________ / 30 Points The chief complain is identified with no identifying factors. The chief complaint is identified at least three identifying factors. The chief complaint is identified with all of the identifying factors. History of Present Illness The history of present illness is identified without the use of OLDCARTS*. The history of present illness is identified with the use of at least four OLDCARTS*. The history of present illness is identified with the use of all of the OLDCARTS*. Past Medical History The past medical history The past medical history is partially identified. is identified. Past Surgical History The past surgical history The past surgical history is partially identified. is identified. Medications The medications are partially identified. The medications are identified. Allergies The allergies are partially identified. The allergies are identified. Family History The family history is partially identified. The family history is identified. Review of Systems The review of system is identified with only the system that is pertinent to the chief complaint. The review of system is identified with the use of at least three various systems. OBJECTIVE The review of system is identified with the use of a minimum of five various systems. _________ / 08 Points Vital Signs The vital signs are partially identified. The vital signs are identified. Physical Examination The physical exam is identified with only the system that is pertinent to the chief complaint. The physical exam is identified with the use of at least three various systems. ASSESSMENT The physical exam is identified with the use of a minimum of five various systems. _________ / 06 Points Assessment An assessment of the patient’s condition is partially provided. An assessment of the patient’s condition is provided. ICD Code An ICD code is partially An ICD code is identified for the identified for the condition. condition. 3 MEDICAL TERMINOLOGY PLAN Plan _________ / 05 Points The patient’s plan includes only one factor (i.e. to admit or not to admit, medications, and diet). The patient’s plan includes at least two factors (i.e. to admit or not to admit, medications, and diet). The patient’s plan includes at least three factors (i.e. to admit or not to admit, medications, and diet). FORMAT Format _________ / 01 Points The paper was correctly formatted. TOTAL: ________ / 50 Points * OLDCARTS stands for Onset, Location, Duration, Characteristics, Alleviating or Aggravating, Radiating, Timing, and Severity. 4 ! 22S_BIO2020.01-1 Pages On The Cusp Immersive Reader Spring Semester 2022 Account Home On The Cusp Announcements Dashboard Courses Modules Assignments A 27-year-old man presented to the emergency department with a 5-day history of fevers. One week before presenta!on, he began to have conges!on, rhinorrhea, cough, and fa!gue a”er exposure to a coworker who had an upper respiratory infec!on. At the same !me, he noted an oral ulcer, which subsequently resolved. He then had fevers… Grades Groups Calendar 20 Inbox History People Case Presenta!on Course Evalua!ons A 27-year-old man presented to the emergency department with a 5-day history of fevers. One week before presenta!on, he began to have conges!on, rhinorrhea, cough, and fa!gue a”er exposure to a coworker who had an upper respiratory infec!on. At the same !me, he noted an oral ulcer, which subsequently resolved. He then had fevers, with temperatures as high as 39°C (102.2°F). On further ques!oning, he reported having nausea, vomi!ng, chills, rigors, and diffuse arthralgias during the 2 days preceding presenta!on. The pa!ent did not have diarrhea, headache, photophobia, neck s!ffness, rash, or shortness of breath. He reported no recent !ck or insect bites, an!bio!c use, injec!on-drug use, or recent dental or surgical procedures. Before his current illness he was physically ac!ve and had been able to run and li” weights at a gym several !mes a week. Help History The pa!ent’s medical history. Medical History A heart murmur was noted on rou!ne examina!on when pa!ent was a child. An echocardiography revealed a small, restric!ve, membranous ventricular septal defect, with a peak le”-to-right gradient of 120 mm Hg, a patent foramen ovale with trace le”-to-right shunt flow, and a bicuspid aor!c valve with mild aor!c regurgita!on. He received conserva!ve treatment, with no surgical interven!on, at a congenital heart disease clinic. Un!l 4 years before his current presenta!on, the pa!ent had annual echocardiography. The images showed con!nued stability in the size and func!on of the le” and right ventricles, with no indica!on of progression of congenital heart disease. Family History Mother: Depression Father: Substance Abuse NOTE: There is no known family history of autoimmune or rheumatologic diseases, sudden cardiac death, early myocardial infarc!on, or structural or congenital heart disease. Social History Medica!ons The pa!ent works at a restaurant. The pa!ent is in a monogamous rela!onship with a female partner. The pa!ent consumes up to 10 alcoholic drinks per week. The pa!ent reports no recent drug use, but did use cocaine and intravenous heroin for a brief period more than 3 years before current presenta!on. None. Allergies No known allergies to drugs or environmental allergens. Physical Examina!on The pa!ent’s physical examina!on. Vital Signs Nervous System Temperature, 39.4°C Heart Rate, 108 BPM Blood Pressure, 127/63 Respiratory Rate, 18 Oxygen Satura!on, 95% Ill-Appearing Tachypneic A&O X3 HEENT Fully conversant. No facial asymmetry or focal cranial nerve deficits. Muscle strength symmetric and equal on both sides of body, sensa!on to light touch and pain intact, reflexes brisk and symmetric. Lungs Pupils equal and reac!ve to light, without photophobia. No conjunc!val hemorrhages. Moist mucous membranes with no oral lesions or ulcers. Supple neck, without nuchal rigidity. No cervical lymphadenopathy. Abdomen Pleural rub in both lungs. Both lung fields otherwise clear to ausculta!on. Heart Rate regular but tachycardic. S1 and S2 sounds normal, without increased P2 component; no S3sound Hyperdynamic, harsh holosystolic murmur heard best along sternal border (similar to four years earlier). Extreme!es Nontender. No appreciable hepatosplenomegaly. No edema in legs or ankles. No cyanosis, clubbing, or nailbed abnormali!es. Skin No rashes. No macular or nodular lesions on hands or feet. Laboratory Results The laboratory studies revealed hyponatremia, hypokalemia, and elevated levels of crea!ne kinase and N-terminal pro–B-type natriure!c pep!de (NTproBNP). Although the crea!nine level is within the normal range, it is elevated from a baseline of 0.8 mg per deciliter 1 year before presenta!on. The white-cell count is normal, but the differen!al count shows a high percentage of neutrophils and band forms. The pa!ent has thrombocytopenia. The pa!ent’s blood was drawn for culture. The pa!ent’s laboratory results. Variable Result Normal Range Flag Hematocrit 40.2 16.0-48.0 Hemoglobin 13.3 11.5-16.4 White Cell Count 7,450 4,000-10,000 Neutrophils 82 48-76 High Lymphocytes 0 18-41 Low Monocytes 3 4-11 Low Eosinophils 0 0-3 Basophils 0 0-1.5 Bands 9 0-3 High Platelet Count 48,000 150,000-50,000 Low Sodium 124 126-142 Low Potassium 3.1 3.5-5.0 Low Chloride 91 98-108 Low Bicarbonate 25 23-32 Urea Nitrogen 23 9-25 Crea!nine 1.2 0.7-1.3 Glucose 125 34-118 Lac!c Acid 1.3 0.3-2.2 Troponin-T 7.77 7.0 4.4 4.1 7.7 >7.7 Total 4.6-10.7 >24.9 22.9 17.1 17.5 22.3 >21.7 Total Triiodothyranine 80-200 390 239 286 272 310 >349 Thyroidectomy On examina”on a!er surgery, the pa”ent’s thyroid gland was diffusely enlarged, with the le! lobe weighing 80.0 g and the right lobe weighing 70.9 g. The total weight of a normal thyroid gland is es”mated at approximately 10 to 20 g. On histopathological analysis, both lobes showed diffuse hyperplasia, fibrosis, and mild chronic inflamma”on, all of which are consistent with Graves’ disease. No parathyroid “ssue was visible. The following laboratory results were collected one day post-surgery. The pa”ent’s laboratory results one day a!er surgery. Variable Results Normal Range Flag Parathyroid Hormone 3.4 15-65 Low Calcium 7.2 8.8-10.7 Low 25-Hydroxyvitamin D 33 25-80 Phosphorous 3.5 2.4-4.3 Albumin 4.6 15-65 Low Magnesium 2.2 8.8-10.7 Low Thyrotropin 0.0006 25-80 Low Free 1.7 0.9-1.7 Total 21.7 4.6-10.7 Total Triiodothyronine 97 80-200 Thyroxine High Management and Outcome Hospital Course The pa”ent had a gradual but good recovery from surgery. On postopera”ve day one, he was hypocalcemic (calcium level, 7.2 mg per deciliter), and his parathyroid hormone level was inappropriately low (3.4 pg per milliliter). Calcium supplementa”on and the administra”on of calcitriol were ini”ated to achieve a serum calcium level of 8.0 to 8.5 mg per deciliter. The beta-blocker dose was tapered and discon”nued during the first seventy-two hours a!er surgery. An”thyroid medica”ons and potassium iodide were discon”nued immediately a!er surgery. Glucocor”coid doses were tapered over the first seventy-two hours a!er surgery. Thyroid hormone–replacement therapy was prescribed on postopera”ve day three. The pa”ent was successfully extubated and awakened on postopera”ve day four. His mental status had returned to normal. Post-Hospitaliza!on Recovery The pa”ent remained persistently hypocalcemic for several weeks a!er the surgery, with a low but measurable parathyroid hormone level. Oral calcium tablets and calcitriol were con”nued, with the goal of keeping calcium levels in the low-to-normal range. Three months a!er surgery, the pa”ent’s parathyroid hormone and calcium levels had risen to the normal range, and calcium supplementa”on and calcitriol were reduced and discon”nued. “Previous Next# ! 22S_BIO2020.01-1 Pages A Pa!ent with Fever and Dyspnea Immersive Reader Spring Semester 2022 Account Home A Pa!ent with Fever and Dyspnea Announcements Dashboard Courses Modules Assignments Grades Groups People Course Evalua!ons Calendar 20 Inbox History Help A 60-year-old woman who lived in Massachuse”s presented to the emergency department in March 2020 with a 5-day history of fevers and chills… Case Presenta!on A 60-year-old woman who lives in Massachuse”s presented to the emergency department in March 2020 with a 5-day history of fevers and chills. She reported no rhinorrhea, sore throat, or loss of smell (anosmia) and no focal neurologic symptoms. She had no rashes or urinary symptoms. Four days before presenta!on, the pa!ent had gone to an urgent care center, where she reported the recent development of fa!gue and myalgias as well as fevers and chills. The test results for influenza were nega!ve. She took acetaminophen at home with some relief of symptoms, but during the next two days, dyspnea developed along with a dry cough, nausea without vomi!ng, and watery diarrhea. The pa!ent recalled no sick contacts, but she had traveled to the United Kingdom one month before presenta!on and to Westchester County, New York, one week before presenta!on. Westchester County had since been recognized as having an outbreak of coronavirus disease 2019 (COVID-19). She was admi”ed to the hospital during her visit to the emergency department. History The pa!ent’s medical history. Medical History Family History Hypothyroidism Vitamin D Deficiency Childhood Asthma Mother: Breast Cancer, Deceased Father: Pulmonary Fibrosis Brother: Lung Disease Medica!ons Social History The pa!ent lives alone in Massachuse”s. The pa!ent works as a professor at a university. The pa!ent runs regularly and engages in other athle!c ac!vi!es. The pa!ent reports no use of tobacco, alcohol, or intravenous drugs. Levothyroxine, 50 µg, Every Morning Allergies No known allergies to drugs or environmental allergens. Physical Examina!on Vital Signs Lungs Temperature, 39.2°C Heart Rate, 87 BPM Blood Pressure, 108/70 Respiratory Rate, 16 Oxygen Satura!on, 92% Fa!gued Bibasilar crackles. No wheezing or rhonchi. No tenderness to percussion. No fluid on ausculta!on. No use of accessory muscles for breathing or respira!on. Heart Back Normal rate and rhythm. No murmurs. No jugular venous disten!on. HEENT No scleral icterus. Clear oropharynx with moist mucous membranes. Supple neck, with full range of mo!on; no nuchal rigidity. No cervical lymphadenopathy. Abdomen So# and nondistended. Nontender to palpa!on throughout; no rebound or guarding. Bowel sounds appreciated. No hepatosplenomegaly. Arms and Legs No peripheral edema. No clubbing or cyanosis. No calf tenderness. No erythema or warmth. No paraspinal tenderness. Nervous System A&O X3 No gross cranial nerve deficits appreciated. Laboratory Results The pa!ent’s laboratory results. Variable White Cell Count Result Normal Range Flag 6,450 4,000-10,000 Neutrophils 81 48-76 High Lymphocytes 8 18-41 Low Monocytes 2.0 4-11 Low Eosinophils 0 0-5 Basophils 0 0-1.5 Hemoglobin 12.3 11.5–16.4 Hematocrit 36.8 36.0–48.0 Platelet Count 215,000 150,000–450,000 Sodium 136 136-142 Potassium 3.9 3.5-5.0 Chloride 96 98-108 Low Carbon Dioxide 22 23–32 Low Urea Nitrogen 8 9–25 Low Crea!nine 0.72 0.70–1.30 Low Glucose 111 54-118 Calcium 8.2 8.8-10.7 Magnesium 2.3 1.7–2.6 Lac!c Acid 1.3 0.3-2.2 Alanine Aminotransferase 26 10-50 Aspartate Aminotransferase 46 10-50 Alkaline Phosphatase 54 40-130 Total Protein 5.4 6.0-8.0 Low Albumin 2.7 3.5–5.2 Low Total Bilirubin 0.2 0.0-1.0 Lactate Dehydrogenase 375 135–225 High-Sensi!vity Troponin T BC. Motor: The pa!ent lacks involuntary movement, has symmetry of the upper extremi!es and lower extremi!es, and has good muscle tone or bulk strength. The pa!ent has good muscle tone with a strength of 5/5 bilaterally in the elbows, wrists, fingers, hips, knees, and ankles. Fingers: The pa!ent has good grip, abduc!on, thumb opposi!on Hips: The pa!ent has good flexion, extension, abduc!on, and adduc!on. Knees: The pa!ent has good flexion and extension. Ankles: The pa!ent has good dorsiflexion and plantar flexion. Coordina!on: The rapid altering movements is intact with symmetry and smoothness in the upper extremes and lower extremi!es bilaterally. The point-to-point is intact with symmetry and smoothness in the upper extremi!es and lower extremi!es bilaterally. The pa!ent demonstrates regular gait without ataxia and with normal base. Sensory: The pa!ent maintains upright balance with eyes closed in the Romberg Test. The pa!ent has no Pronator Dri$. The sensa!on to light tough and pain is intact bilaterally thought the shoulders, forearms, thumbs, anterior thighs, toes, medial legs, and lateral legs. Reflexes: The muscle strength reflexes of the biceps, brachioradialis, triceps, quadriceps-patellar, and Achilles are two plus bilaterally. The plantar reflex is non-diseased with down going toes. The hyperac!vity reflex is neurologically non-diseased with no evidence of clonus. Meningeal Signs: The Brudzinski Sign is nega!ve with no pain. The Kernig Sign is nega!ve with no pain. There is no sign of meningeal irrita!on. Dermatology: The skin throughout is warm, pink, moist, and without hyperpigmenta!on or hypopigmenta!on. There is no decrease in skin mobility or turgor. There is no rash, petechiae, or ecchymosis. The nails are pink and without clubbing or legions. The capillary refill is under two seconds bilaterally in the upper extremi!es and lower extremi!es. ASSESSMENT: A general adult medical examina!on without abnormal findings (Z00.00). PLAN: The pa!ent has been informed of the risks of poor diet and exercise with a high BMI. He is currently walking thirty minutes, three !mes a week with maintenance and plans in increasing this in the upcoming weeks. The pa!ent will follow-up in one year for an annual physical examina!on. He will return earlier and/or report to the primary care physician if any problems arise prior to this appointment. “Previous Jane Doe, PA-C John Smith, DO 01/01/2022 Physician Assistant Signature Physician Signature Date Next# ! 22S_BIO2… Pages Lower Abdominal Pain Which is Unspecified (R10.30) Immersive Reader Spring Semester 2022 Account Home Announcements Dashboard Courses Modules Assignments Grades Groups People Course Evalua!ons Calendar 20 Lower Abdominal Pain Which is Unspecified (R10.30) The following is a SOAP Note with the diagnosis of a “lower abdominal pain which is unspecified (R10.30)”. This example represents a problem orientated documenta!on. The purpose of this example is to provide a template for the “expected” pa!ent based off of the provided interac!ve clinical cases. It should be noted that one is expected to present five systems in the “Review of Systems Examina!on” and “Objec!ve Examina!on”. In the instance that you are unsure of which systems to include, it is highly recommended that one review this document for guidance. I recommend u!lizing [1] the system presented in the chief complaint, [2] the system(s) directly above and below the system men!oned previously, and [3] the “General Survey”. Inbox SUBJECTIVE: History Help CC: Jane Doe is a 17-year-old Hispanic male who presented with right lower quadrant abdominal pain to the emergency room (DOB 01/01/2003). HPI: The pa!ent is reques!ng the emergency department determine the cause of the right lower quadrant abdominal pain, including appendici!s. She states that the pain started yesterday at 7:30 PM and was localized to the right lower quadrant of her abdomen. The pa!ent was in “excrucia!ng, unbearable pain” and unable to sleep. The pa!ent reports that she was in pain when walking but had some relief with the ibuprofen that was given in the emergency department. The pa!ent was admi#ed to the hospital. The pa!ent denied diarrhea, cons!pa!on, nausea, vomi!ng, fever, or shortness of breath. Upon examina!on the morning a$er admi#ance, the pa!ent has very mild pain. She is able to walk without discomfort and is res!ng comfortably. SocHx: The pa!ent lives at home with her mother and father. She has no history of EtOH, tobacco, illicit or illicit drugs being used by either herself or immediate family member. The pa!ent is currently enrolled in high school and receives a minimum of sixty minutes of exercise each day. She par!cipates in cheerleading. The immuniza!ons for this pa!ent are up to date. PMHx: The pa!ent’s mother denies previous remarkable medical history. PSHx: The pa!ent’s mother denies previous surgical history. Medica!ons: The pa!ent is not currently taking any medica!ons. Allergies: The pa!ent has no known drug allergies. FHx: The mother and faster are both alive with unremarkable past medical history. The pa!ent’s paternal grandmother has breast cancer. ROS: HEENT: The pa!ent denies ear pain, ear swelling, loss of hearing, runny nose, sore throat, or painful swallowing. Respiratory: The pa!ent denies coughing. Abdominal: The abdomen is mildly tender to palpa!on in the lower right quadrant and lower le$ quadrant. The pa!ent reports one incident of diarrhea at 3AM. The pa!ent reports nausea and diarrhea. The pa!ent denies vomi!ng. MSK: The pa!ent denies any aches or pains. The pa!ent walks freely without pain. General Survey: The pa!ent states that she “feels fine”. The pa!ent denies fever or recent weight loss. OBJECTIVE: Vital Signs: BP 104/65. PR 100. T 99.1 F PO. R 18 Regular. Ht 165.1 cm. Wt 54.4 kg. BMI 20.0. LMP 12/15/2021. General Survey: The pa!ent is alert, orientated, coopera!ve, and well developed. The pa!ent is well nourished with no appreciable disease. The pa!ent appears stated age. HEENT: Head: The head is normocephalic. The hair distribu!on is even and full. The head is without deformi!es, bumps, lesions, tenderness, or swelling. Eyes: The vision is 20/20 OD, OS, and OU without correc!on. The upper and lower eyelids are pink with no lesions or edema. The sclera is white. The conjunc!va is pink with no edema or lesions bilaterally. The cornea is without opaci!es and ulcera!ons. The iris is brown without crescent shadows or lesions. The extra ocular movements are parallel and conjugate bilaterally. Ears: The auricle and pinne are without deformi!es, lesions, or tenderness bilaterally. The external auditory canal is without discharge, redness, or swelling. There is minimal yellow cerumen bilaterally. The tympanic membrane is bilaterally are pearly grey in color without fluid or perfora!on. The cone of light reflected in the appropriate areas and the tympanic membranes are mobile. Nose: The nares are patent. The nasal septum is without bleeding, devia!on, or perfora!on. The nasal mucosa is pink with no edema, erythema, exudates, or growths. Throat: The lips are norm-pigmented with no erythema, cracking, or ulcers. The oral mucosa is pink and moist with no nodules or white patches. The gyms are pink with no gingivi!s, swelling, or ulcera!on. The teeth are intact. The hard palate and so$ palate are pink, moist, and without lesions. The tongue is pink, moist, and without lesions on the floor of the mouth. The tonsils are present bilaterally with no exudates or swelling. The uvula is midline and the postpharyngeal wall is pink. Pulmonary: The respiratory rate is within range. It is regular, unlabored, and with adequate depth. There are no external audible breathing sounds. There are no signs of retrac!ons, accessory muscle use, and respira!ons are non-labored and symmetrical. There are no chest wall masses or tenderness on palpa!on. The lungs are clear with ausculta!on with no W/R/R. There are no adven!!ous sounds. Heart: The anterior chest is without heaves. There are no thrills, heaves, or bruits in the aor!c, pulmonic, tricuspid, and mitral areas of the precordium. There is regular rate and rhythm and no spli%ng of S1 or S2. There are no clicks, opening snaps, S3, S4, or ejec!on sounds. There are no murmurs, gallops, or rubs. There were no special tests indicated. Abdomen: The abdomen is without scars, striae, dilated veins, or rashes. The contour is flat and without any visible masses, peristalsis, or pulsa!ons. In all four quadrants, the bowel sounds are hypoac!ve. There was no guarding or rigidity. There was some tenderness in the lower right quadrant. There are no masses, organs, or pulsa!ons on palpa!on in all four quadrants. There is no kidney tenderness or enlargement. The McBurney, Obturator, and Psoas were nega!ve. There is no rebound tenderness. Musculoskeletal/Extremi!es: The arms are symmetrical with no edema and venous engorgement bilaterally. The skin temperature is warm and pink. The legs are symmetrical with no edema, lesions, or rashes. The skin is pink and hair distribu!on is even. The capillary refill is within two seconds. Mental Status: The pa!ent is alert, orientated to the date of the week, place and person. The pa!ent is relaxed and coopera!ve. The CN II-XII are grossly intact bilaterally. ASSESSMENT: An ultrasound and CT scan were conducted which revealed a lumen diameter of 5 mm in the appendix. A diameter of 8 mm is necessary for a diagnosis of appendici!s. A CBC was also conducted, and this showed minimally elevated WBCs of 13.4. Overall, the diagnosis of appendici!s is low; however, a general surgery consult was arranged. The results of a mycoplasma test are pending. The diagnosis for this pa!ent is lower abdominal pain which is unspecified (R10.30). PLAN: 1. Admit 2. Diet: So$ Foods Diet 3. Medica!ons: A. IVF Hydra!on B. Acetaminophen C. Morphine D. Zofran 4. Laboratories: A. CBC: WBC 13.4 B. CMP: Unremarkable C. UA: Unremarkable D. Mycoplasma: Pending 5. Consult: General Surgery The pa!ent will be admi#ed to the hospital with diet and medica!ons as indicated above. I contacted the general surgery physician on call at 19:00 and am currently awai!ng for them to return the call (physician is currently in surgery). “Previous Jane Doe, PA-C John Smith, DO 01/01/2022 Physician Assistant Signature Physician Signature Date Next#
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