Create a SOAP note for this FOCUSED assessment. Case #2 SUBJECTIVE:… Create a SOAP note f

Create a SOAP note for this FOCUSED assessment. Case #2 SUBJECTIVE:… Create a SOAP note for this FOCUSED assessment. Case #2 SUBJECTIVE: CC: “I am having pain with urinating” HPI: A 65-year-old Asian male presenting with complaints of having pain when he voids as well as lower abdominal and back pain for the last three to four days. He states that he will get intense cramping in his abdomen and feel like he needs to void but cannot. He reports he has been drinking plenty of water and has taken a sitz bath to help with voiding. He reports that once he can void the abdominal and back pain resolves until he needs to void again. He states that he has not had any nausea or vomiting, nor has he noted any blood in the urine. He reports that the back pain is the same back pain he was having before but more intense when he has the abdominal cramping. He reports he tried the baclofen but had side effects from the medication. He reports he saw his oncologist last week and was told that his kidney function and blood counts were stable. He reports he had a CT scan of the abdomen and pelvis as well as chest done in the last 3 months and was informed everything was normal. He reports he does have a ureteral stent in place and has not seen his urologist recently. PMH: Colon Cancer stage 3 metastasized to liver and peritoneal cavity, neuropathy that is secondary to chemotherapy, recurrent urinary tract infections, chronic constipation, degenerative joint disease lower lumbar spine Surgical history: Right ureter stent placed 3 months ago, upper right chest port placement two years ago, appendectomy – age unknown, hernia repair with mesh 2000 Allergies: no known drug allergies Medications:1-Flomax 0.4mg capsules one every 12 hours for to aid in urination, lactulose 10grams/15mL twice daily for constipation, ibuprofen 200mg tablet – four every six hours as needed for back pain, Actifed over the counter (OTC) as needed for runny nose, and Oxycodone 5mg tablets – one every six hours as needed for pain. Social history: He is divorced and lives alone. He is also retired and enjoys spending time with his family and friends. He enjoys the outdoors and fishing. He reports he was a former smoker but quit in the 1980’s. He reports occasional alcohol intake, denies illicit drug use and reports a moderate amount of caffeine intake with coffee. Family history: He reports his father is deceased with malignant tumor of prostate. Mother is deceased with heart failure and paternal grandfather also deceased with malignant tumor of prostate. Health Maintenance/Promotion: He reports he takes the influenza vaccination and has had two pneumococcal vaccines recently.  REVIEW of SYSTEMS: General: A 65-year-old Asian male reporting difficulty voiding, lower abdominal and low back pain. He reports no chills, fever, night sweats or weight changes. Skin: Denies changes to skin and denies any new lesions, rashes or dryness. HEENT: Denies any head trauma, nodules or lesions to scalp. Denies headache, light-headedness, numbness or facial pain. He denies blurred vision, spots or tearing. He denies ear pain, hearing loss, popping sound, ear drainage or vertigo. He denies any present nasal discharge or epistaxis, He reported occasional seasonal sinusitis but has not had any problem thus far. He denies difficulty with smell or taste of food. He denies gum, lip, or mouth pain. He reports upper and lower denture set. Denies throat discomfort or difficult swallowing. Neck: Denies neck stiffness, swelling, or nodules. CV: Denies palpitations, tightness or chest discomfort, edema, or shortness of breath.  Lungs: Denies cough, congestion, wheezing, shortness of breath or breathing concerns. GI: Reports abdominal pain – see HPI. Reports a mass to upper right abdomen that has not changed in size. Denies nausea, vomiting, or diarrhea. He denies gastro reflux discomfort or indigestion. He reports occasional constipation. He reports that his bowel habits have been unusual the last few days with having a normal bowel movement every four to six hours while awake and he is denying clay, tarry, or black colored stools. Denies any recent bleeding disorders or anemia. He reports his appetite has not been good the last few days. GU: Reports lower right abdominal and flank pain, urine urgency and difficulty voiding, He reports sometimes there is burning. He denies blood in urine. PV: Denies cramps, numbness, and tingling. Denies swelling or varicose veins. Denies discoloration to nail beds. MSK: He reports he has noticed an unsteady gait the last few days and finds himself holding on to something when he initially gets up. He denies muscle stiffness or decrease range of motion. He denies any bony abnormalities or joint swelling. He denies use of assistance devices. Neuro: Denies memory loss, difficult speaking, dizziness, problems with concentration, or seizures. Denies extremity tingling. Reports recent problem with walking. He denies problems with sitting or lying. He denies generalized weakness. Endo: Denies excessive thirst or hunger, hot and cold intolerance, excessive sweating, or thyroid dysfunction.  Psych: Denies anxiety, moodiness, depression, or suicide ideations.  OBJECTIVE: Gen: A 65-year-old Asian male whom is well-nourished, well-developed, well-groomed, ambulating normally whom appears to be chronically ill and in mild distress. He is oriented to person, place, time, and situation. VS: Temp-97.9*F (tympanic), B/P-119/67- R arm sitting, HR-91 bpm, RR-16, Pulse Ox-95% on Room Air Weight – 190lbs, Height – 6’2″ with a BMI of 24.5. SKIN: Symmetrical face, tan in color, skin warm and dry, with good elasticity skin turgor noted to return on top of right hand, multiple discolored spots and bruising noted to lower forearms. There are no open lesions or rashes present to forearms. HEENT: He is bald with no lesions, nodules or deformities to scalp. Bilateral eyes equally round at 2mm with pupils reactive to light, white scleral and clear conjunctiva with no swelling, no ptosis noted, and extraocular movement is present. There is no frontal or maxillary tenderness. External ear structures are normal with clear canals and normal tympanic membranes and landmarks easily identified. Normal nasal mucosa, no obstruction to turbinate’s, no external lesions, and no septal deviation. There is no nasal drainage. The lips are moist and pink with no lesions present, no lesions at gums and no mouth ulcers. The tongue is symmetric, midline uvula, no erythema to posterior pharynx. Midline trachea as well as thyroid, no swelling present and no tenderness on palpation. Neck is supple, no cervical lymphadenopathy or tenderness bilateral, and no supraclavicular lymphadenopathy. CV: Regular rate and rhythm with S1 and S2 present, no murmurs, rubs, or gallops and no carotid bruits. No lower extremity edema. Lungs: Chest movement symmetric, clear bilateral breath sounds, good air exchange, no rales, rhonchi, or wheezing. No axillary adenopathy. ABD: Bowel sounds active and normal x 4 quads, soft, non-distended, no costovertebral angle (CVA) tenderness. There is a small mass noted at the upper right quadrant with mild tenderness in lower abdomen bilaterally. There is no rebound tenderness or guarding. The liver and spleen are palpable and non-tender. No renal bruits. Patient declined rectal exam. GU: Omitted PV: No edema and no discoloration noted to lower extremities. No varicose veins. Radial, femoral, popliteal, and pedal pulses present and strong. There is no discoloration of nail beds. MSK: There was a slow irregular gait noted on moving from chair to exam table. However, there was normal motor strength and muscle tone. His bilateral hand grip is strong and equal as well as leg pushes. No erythema. There is lumbar tenderness present, and negative straight leg. There are no masses felt on lumbar region. There is no shoulder drooping noted. Neuro: He does not appear to be anxious or agitated. There are no tremors present. He can move all extremities symmetrical, finger to nose is intact. Reflexes present to patellar, biceps, triceps, and Achilles deep tendon. He reveals normal speech, tone, and concentration. Diagnostic Tests: Urinalysis, Dipstick with results of moderate leukocytes, moderate amount of bilirubin, and trace of blood. Negative for nitrite, ketones, protein, and glucose, pH 7.0, specific gravity 1.005, urobilinogen 1.3, amber in color, clear     Health Science Science Nursing NU MISC Share QuestionEmailCopy link Comments (0)

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