University of South AlabamaNU nu 545AHN 573-819, Comprehensive SOAP Note IM.

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Running head: COMPREHENSIVE SOAP NOTE 1 AHN 573-819: Comprehensive Soap Note Heather L. Distelrath University of South Alabama Comprehensive SOAP Note 2 AHN 573-819: Comprehensive Soap Note Pati... ent Information: Date of Encounter: 3/15/17 9:00 A.M. D.H. is a pleasant 51-year-old, white male seen on the medical floor. Birthdate: 11/30/1965 Insurance: Humana PPO Source and Reliability: Information comes from the patient. Patient appears to be appropriate and a reliable source of information. S – Subjective Data Chief Complaint (CC): “I have chest pain on the right side and it hurts more with deep breaths.” History of Present Illness (HPI): D.P. is a very pleasant 51-year-old male with an unfortunate past medical history of stage IV squamous cell carcinoma of the left lung with metastasis to the contralateral lung and the skeletal system. He was initially diagnosed in February 2016 and has been on maintenance chemotherapy per his oncologist, last dose of necitumumab was 7 days ago. Mr. P.’s other pertinent history consists of COPD, bullous emphysema and tobacco abuse. The patient states he has been having a few episodes of right sided chest pain in the last two weeks that is aggravated by him turning on to his right side. When the episode occurs, he gets a very sharp, stabbing pain in his right chest area. He reports that it feels like someone is poking his from the inside with a knife. He states associated symptoms are some shortness of breath and diaphoresis. This mostly happens at night and he rates the pain 8/10. Coughing makes the pain worse. The episodes are severe and have been happening more frequently which resulted in the patient presenting to the emergency department last night. He denies having this problem in the past and denies radiation of the pain. He also denies fever, chills, night sweats, weight loss or productive cough. He states he has not taken any medication for the pain at home. The episodes last 10-15 minutes long and the pain is relieved with repositioning, rest and deep breathing exercises. A CTA was done in the ED and shows severe bullous emphysema with new consolidation and pleural effusion in the left upper lobe concerning for infection or worsening neoplastic process. At the time of evaluation, the patient states he is feeling better, denies pain and states the sharp right sided chest pain and dyspnea has subsided. Past Medical History (PMH):  Childhood illnesses: Positive for Chicken pox. Denies measles, mumps, rubella or rheumatic fever.  Immunizations: Patient received all childhood vaccinations. Polio vaccine, year unknown. MMR, date unknown. Pneumococcal vaccine in September 2016. Flu vaccine in September 2016.  Screening Tests: Patient is up to date with his yearly primary care visit and lipid panel has been within normal limits. Patient has never had a colonoscopy. Comprehensive SOAP Note 3  Major adult illnesses: Chronic obstructive pulmonary disease with home oxygen HS PRN, Bullous emphysema, and non-small cell lung cancer stage IV (T4 N2 M1b).  Hospitalizations: February 2016 for shortness of breath and new cancer diagnosis. o July 2016 for scalp abscess and IV antibiotics.  Past Surgical History: March 2016 Mediport placement. o Tonsillectomy at age 21 o Vasectomy at age 30  Injuries/Accidents: None to date.  Current medications: o Albuterol 90mcg Inhaled TID PRN o Pepcid 20mg PO BID o Restoril 15mg PO QHS PRN o Nicotine 21mg/24hour -1 patch Topical Daily o Zofran 8mg IV Q8hr PRN o Oxycodone 15mg PO Q4hr PRN o Anoro Ellipta 62.5-25mcg Inhaled Daily  Allergies: No known allergies to medications, dyes or environmental factors. [Show More]

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