Abdominal exam soap note

Abdominal exam soap note

W is a year-old man who complains of having a sore throat for 3 days. He denies symptoms of cough, coryza, or rhinorrhea. W is otherwise healthy. He has had no recent sick contacts and no recent travel. He is a heterosexual male, married, and monogamous with his wife. He has no history of blood transfusions or illicit drug use. The physical exam is notable for temperature of Sclera and conjunctiva are not injected. Oropharyngeal exam reveals bilateral tonsillar hypertrophy and exudates without ulcers.

He has no cervical lymphadenopathy on exam. His abdominal is soft with normal bowel sounds. Skin exam is unremarkable. W has 3 points on the modified Centor Score fever, exudate, and absence of cough.

abdominal exam soap note

A RADT test is performed. A RADT test is performed and is positive. W has no allergies to antibiotics and he is treated with penicillin mg twice daily for 10 days. Two days after starting treatment, he reports improvement in symptoms. Symptoms began abruptly 3 days ago when he developed a sore throat, pain with swallowing, fever, and headaches. Patient is otherwise healthy. Denies recent contact with sick and recent travel. Patient is a heterosexual male, married monogamous with his wife.

Oropharyngeal exam: Bilateral tonsillar hypertrophy and exudates without ulcers. No cervical lymphadenopathy. The common viral agents causing respiratory infections are rhinovirus and coronavirus. Less common infections should also be diagnosed as well as nonbacterial pathogens such as HIV, influenza A and B and mononucleosis.

Cough, rhinorrhea and coryza are common symptoms of viral pharyngitis, while patients with bacterial pharyngitis or mononucleosis suffer from fever, tender anterior cervical lymphadenopathy, tonsillar erythema. Most patients suffering from influenza experience cough and myalgias.

Infectious mononucleosis, another possible diagnosis is most common in patients ages 15 to 24 and patients often experience malaise and marked adenopathy. Primary HIV infection has similar nonspecific symptoms as pharyngitis and should be considered with high-risk patients. The textbook presentation of GABHS pharyngitis includes abrupt onset of severe throat pain, moderate fever, and headaches.

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Edema and erythema is present in posterior pharynx and tonsils as well as gray-white exudates. Anterior cervical lymph nodes are tender and gastrointestinal symptoms include nausea, vomiting, and abdominal pain.

If untreated GABHS can lastwhen treated with antibiotics symptoms should improve within 48 hours. It is important to treat patients with GABHS pharyngitis to prevent further complications such as acute rheumatic fever, acute glomerulonephritis and suppurative sequelae. Results are available within minutes. Patients should be treated with antibiotics such as penicillin and amoxicillin. In the event of an allergy, first-generation cephalosporins, clindamycin, clarithromycin or azithromycin can be used.

Severity of symptoms should improve, as well as ability to transmit and possibility of complications. Patients who have had 4 or more episodes of severe pharyngitis in a year might consider a tonsillectomy.AGE: 16 years-old. It smells horrific. It has been three days now. The diarrhea is consistent. The diarrhea started three days ago with a sudden onset. There are no alleviating factors. There are no aggravating factors. Associated symptoms include abdominal distention, abdominal pain, decreased appetite.

Denies blood in stool, denies fever, denies dizziness, denies nausea, and denies vomiting. States she completed a prescription of levofloxacin three weeks ago. Surgical: none. Hospitalizations: none. Family History:. Immunizations: Current childhood vaccinations up to date.

abdominal exam soap note

Vaccinations are current including Gardasil. Has received annual influenza vaccine. Family does not want meningococcal at this time. Takes a daily vitamin. Annual check up with primary care provider. Maintanance of asthma and medications. Review of physical health, well being, and psychosocial concerns, nutritional education and guidance, health education and guidance annually Icahn School of Medicine, Carotid pulse palpable with no bruits, no Jugular vein distention.

Intact, grey in color, patent, no scarring noted bilaterally. No sternal retractions. Resonance heard with percussion in all lung fields, dullness noted anteriorly to the left of the sternum from third to fifth intercostals spaces.

SOAP Note and Case Summary

Tactile fremitus is even bilaterally anterior and posterior. Peripheral vascular: extremities are warm without edema, no varicosities or stasis changes, calves are supple and non-tender, no femoral or abdominal bruits. Neuro :. Gait: casual.She relates she has been doing well, except that since February, she has had epigastric pain. She took omeprazole first once daily and then b. She took it for about a month and then tapered to off.

Last week, she had an episode of hematemesis with bright red blood. She reports she was not retching prior to the hematemesis. She had a dark stool, but no frank melena after that. Chest: Clear. Heart: Regular rate and rhythm.

Dysuria SOAP Note

Abdomen: Positive bowel sounds with mild epigastric tenderness. No rebound or guarding. No peritoneal signs. Rectal Exam: No masses and brown Hemoccult-negative stool. The patient has no signs of active bleeding and is currently Hemoccult negative from below. Restart omeprazole b. Check liver tests, CBC, amylase, lipase, and a pregnancy test.

The patient has been taking omeprazole twice per day and ranitidine at bedtime. She reports her reflux has dramatically improved. She had isolated episode of vomiting. Otherwise, she feels much better. She underwent an upper endoscopy, which revealed a large 4 cm hiatal hernia, otherwise normal. Remainder of physical examination is deferred. Reflux is currently much improved on omeprazole, twice per day dose, and ranitidine at bedtime. She is encouraged that if symptoms worsen in the interim, she should contact us.

We did also discuss seeing a surgeon for repairing the hiatal hernia. Most recent colonoscopy was normal. He had been on Asacol and we attempted to switch him to Lialda, but he had a violent reaction with worsening abdominal pain, nausea, vomiting, and headaches. Now, he takes only Cortifoam nightly, and this helps with his symptoms.

CT scan of the abdomen and pelvis a couple of months back was otherwise normal. We tried Donnatal, but he had side effects from this. He was doing quite well for a while, but in the recent past has had some diarrhea with blood. Yesterday and today, he has been feeling better.CC: Mr.

C is a year-old man who complains of dysuria that started suddenly 5 days ago. He reports the pain seems to radiate to his low back and perineum. He denies any penile discharge, rash, nausea, vomiting, or flank pain.

abdominal exam soap note

He has had more difficulty urinating with a weaker urinary stream for the past few days. He also feels some dizziness upon standing.

C is sexually active with several female partners and does not use condoms or other barrier protection. He has no active medical problems but has noted nocturia over the past few months. Temperature is Abdominal exam demonstrates suprapubic tenderness without rebound or guarding and the absence of CVA tenderness. Genital exam is normal, but there is tenderness on gentle prostate exam without any palpable masses.

C was treated empirically with ciprofloxacin, mg twice daily, and azithromycin, 1 g for 1 dose, for acute bacterial prostatitis. Results of the urine culture showedcolony forming units of E coli susceptible to fluoroquinolones.

The urine PCR for gonorrhea and chlamydia was negative. Treatment with ciprofloxacin was continued for 21 days, and his symptoms resolved. He continued to have nocturia and treatment for benign prostatic hypertrophy was started.

S: 57 year old male presents with dysuria for the past 5 days, with pain radiating to his lower back and perineum. Denies penile discharge, rash, nausea, vomiting or flank pain. No sign of CVA tenderness. Normal genital exam. Tenderness on prostate exam with no palpable masses.

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Urinalysis is positive for leukocyte esterase, 10 WBCs per high power field, and blood with 5 RBCs per high power field.

Urine culturecolony forming units of E. P: Ciprofloxacin mg twice daily for 21 days, azithromycin 1 g for 1 dose. Symptoms resolved after the 21 days. Patient continued to have nocturia and treatment for benign prostatic hypertrophy started.A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultationpercussion, and palpation.

The examination begins with the patient in supine positionwith the abdomen completely exposed. The skin and contour of the abdomen are inspected, followed by auscultationpercussion, and palpation of all quadrants. Depending on the findings or patient complaints, a variety of examination techniques and special maneuvers can provide additional diagnostic information.

Auscultation of the abdomen should be performed prior to percussion and palpation, as physical manipulation of the abdomen may induce a change in bowel sounds. Abdominal tenderness may be a sign of numerous conditions see differential diagnosis of acute abdomen and differential diagnoses of abdominal pain.

Clinical science A fundamental part of physical examination is examination of the abdomen, which consists of inspection, auscultationpercussion, and palpation. Positioning Instruct the patient to lie down and expose the patient's abdomen.

If your hands are cold, warn the patient prior to palpating the abdomen. Inspection of the abdomen Note any scars, striaevascular changes e. Purpose: to assess bowel sounds Auscultate over all four quadrants.

Listen for bruits. Normal findings : : gurgling bowel sounds every 5—10 sec Percussion of the abdomen Purpose: to determine the size and location of intra-abdominal organs Percuss over all four quadrants. If so, begin palpation in the non-painful area. Observe the patient's face during abdominal palpationas it is the main indicator of the intensity and location of pain. Procedure: Superficial palpation : to assess for superficial or abdominal wall processes Deep palpation in all four quadrants : to assess intraabdominal organs potential signs of peritonitis Rebound tenderness : abrupt increase in pain when an examiner suddenly releases compression of the abdominal wall.

Caused by irritation of the receptors in parietal peritoneum Abdominal guarding : patient contraction of the abdominal wall muscles during palpation Involuntary guarding also referred to as "rigidity" : involuntary tightening of the muscles due to peritoneal inflammation and is often localized to a specific abdominal quadrant. Voluntary guarding: voluntary contraction in order to avoid pain during the examination and is often generalized over the entire abdomen.

Palpation of the liver Place the pads of your fingers over the right upper quadrantapprox. Palpate as you move towards the right upper quadrant and attempt to feel for the edge of the liver. Continue until you feel the liver or reach the costal margin.

Asking the patient to take a deep breath may facilitate palpation of the liveras the movement of the diaphragm will move the liver toward your hand. Palpation of the spleen Place the pads of your fingers lateral to the belly button and palpate as you move towards the left upper quadrant. Repeat 10 cm below the left costal margin. Asking the patient to lie on their right side may facilitate palpation of an enlarged spleen. Palpation of the inguinal lymph nodes : see examination of the lymph nodes Abdominal tenderness may be a sign of numerous conditions see differential diagnosis of acute abdomen and differential diagnoses of abdominal pain.Marcia Billings, a year-old female ;comes to the emergency department because of abdominal pain.

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress i.

If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks.

Following the link to the patient note form or the abbreviation list will not interrupt your progress. BillingsI understand that you may be sensitive about your weight, and it is not my intention to lecture you.

I can assure you that, as your physician, I want you to be in the very best possible health, and it is my job to look for ways for the two of us to get you there, together. Would you be interested in discussing some options for how we can do that?

To access the sample patient note, you must first submit your own. Please enter your patient note in this form: access the patient note here For reference, see our list of common abbreviations for the patient note, which is similar to the list that will be posted at every station during your CS exam: access the abbreviation list here. Cholelithiasis can lead to cholecystitisbiliary pancreatitisand choledocholithiasis. Opening scenario Marcia Billings, a year-old female ;comes to the emergency department because of abdominal pain.

Vital signs Temperature: Explain the preliminary differential diagnoses and initial workup plan to the patient. Write the patient notes after leaving the room. Patient instructions Sit hunched forward and act as if you have severe abdominal pain.

Point at the middle and upper right part of your abdomen when the examinee asks you about the location of your pain.

How to Document a Patient Assessment (SOAP)

Tell the examinee that the pain is especially bad when they press on the middle and upper right part of your abdomen. When the examinee asks you to breathe in while they press on the upper right part of your abdomen, start to breathe in and then stop suddenly because of severe pain. You are not aware of the meanings of medical terms e. Use the checklists below for history, physical examinationand communication and interpersonal skills. History of present illness Chief complaint Pain in my stomach.

Location In the middle and upper right part. Intensity on a scale from 1—10 8—9. Quality Dull. Onset 12 hours ago. Precipitating events It started pretty soon after dinner yesterday. I think it is actually getting worse. Previous episodes None like this.

Patient Examination Series- Dr Hollie Berry

I have had some stomach pain after meals beforebut it has always gotten better after a couple of hours. Radiation It hurts really bad all the way around to my back.

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And I also have some pain in my right shoulder. Alleviating factors I tried a warm water bottle, but that did not do anything. Sitting hunched ; over or lying on my side seems to help a little.Caitlin Goodwin is a Certified Nurse-Midwife and birth nerd with 12 years in obstetric nursing.

Proper charting is an essential form of communication among healthcare professionals. Healthcare providers need to be fluent in SOAP notes because it provides concise and complete documentation that should describe what you observed, what data you collected, and what you did.

Take full credit for your hard work! General appearance: Is the patient alert and oriented? Is the patient in mild, moderate, or severe distress? Does the patient appear healthy and well-nourished? Labs: Write down the results of any labs that are relevant and available today Urinalysis, blood sugar, labs and available from the prior visit.

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Imaging: Include any imaging results from the prior visit like the dating, Nuchal Translucency NTAnatomy or growth ultrasounds. The diagnosis can be as simple as intrauterine pregnancy and gestational age or specific to a disease process. If you are concerned about differentials, these should be listed too. CC: Unintended pregnancy, pt is accepting but overwhelmed.

Unmarried, FOB involved. Presenting for OB care as a new patient, first antepartum visit. Unsure intercourse timing. Amenorrhea, increased frequency of urination, fatigue and breast tenderness began about four weeks ago. Denies dizziness, HA, visual disturbances, edema.

Denies vaginal discharge, odor, bleeding, and cramping. Eats fruits and hydrates appropriately. Pt is not currently exercising. Never smoker. Christian, non-denominational No domestic violence. Does not have a cat, no litter box. Personal — Denies History of abuse, mental illness, depression, anxiety, or eating disorders. The sinuses are nontender. Pupils are equal and reactive.

The nares are patent. The oropharynx is clear without lesions. Fetus: Bimanual exam presents as approximately 9 wks gestation.

FHTs ss. No fetal movement. Category II tracing- Continuous electronic fetal monitoring, consider amnioinfusion if decelerations worsen.


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