(SOAP NOTE) NR511 WEEK 4 M. MILLER Patrick Smith 42 YO(CC
Pain 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
1|Page
, 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.
2|Page
