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problem statement: Patient initials: J. H. Age: 50 Sex: Male Marital Status: Married Race: Caucasian Occupation: Police dispatcher Source of Information: Patient; appears reliable Problem Statement: “I’m here for a physical. It’s been about a year since I’ve seen a doctor. My wife and I are applying for foster parent status and are required to have a physical”. Subjective HPI: 50 y/o white male presents today for annual physical. Patient states requires physical for foster parent status approval. Patient states that he is usual state of “good health”. Reports that he has occasional “problems with hemorrhoids” (occasional notice of bright red streaks on stool and toilet paper after passage of large hard stools). States that his hemorrhoids are not currently causing him any problems. He also reports occasional and self-limiting episodes of diarrhea, which he attributes to stress (currently symptom free). Denies chest/abdominal pain. States usually has one formed stool in morning. Denies change in bowel frequency or consistency (except as previously noted). Denies nausea/emesis. Denies dark tarry stools. Denies recent weight gain/loss. Eats regular diet with no recent changes. His only other complaints are for seasonal itchy eyes, sneezing, and runny nose (currently symptom free). Pertinent Medical Denies chronic medical conditions. Immunizations up to date (last TD 2006). States passed 5mm kidney stone 2007. Right ankle fracture (non-displaced, football) 1991. Preventive screenings: colonoscopy (never). Patient does not want colonoscopy because he does not like the, “idea of anesthesia”. Last eye exam 2010, last dental exam 2009. Current Medications NKDA. Ibuprofen, 600mg PO prn knee pain.
Surgical History Vasectomy 2007. Family History Father died at 74 years of age from “prostate cancer that traveled to brain”. Mother living (85 years old) has history of “glaucoma and osteoarthritis”. Has one sibling (brother, 57 years old) with history of “hypertension, otherwise in good health”. Social History The patient reports his health to be “pretty good”. He never smoked and admits to drinking 1 six-pack of beer every month or so. The patient is married and has no children. He is physically active outside of work (plays intramural baseball and takes care of his three horses), but does not participate in routine aerobic exercise. He consciously watches his caloric and fat intake, but is otherwise on a regular diet. He is sexually active in a monogamous relationship. He denies the use of recreational drugs. His wife also works outside of the home and they are both self-supportive on their current combined incomes. He has no current concerns regarding his activities of daily living. Review of Systems General Reports in usual state of “Good” health and weight. Denies fever, chills, recent weight gain or loss, weakness, fatigue, pain. States that his last physical exam was in 2010. Skin Denies recent rashes or changes in texture or moles. HEENT Denies headaches. Denies problems with vision or hearing. Wears reading glasses, last eye exam 2010. Denies use of hearing aids. Denies glaucoma or cataracts. Denies frequent nasal congestion/stuffiness, but occasional seasonal teary eyes, runny nose and sneezing (currently asymptomatic). Denies nosebleeds. Denies permanent/removable dental prosthetics. Last dental exam 2010. Denies swollen glands/limps, neck stiffness. Thorax and Lungs Denies history of lung disease, allergies, or asthms. Denies episodes of unexplained shortness of breath. Cardiovascular Denies “heart trouble”, high blood pressure, rheumatic fever, heart murmurs, irregular beat, palpitations, or chest pain/discomfort. No prior stress test or EKG. Peripheral Vascular Denies extremity edema, coldness, leg cramps, skin ulcers. Abdomen Regular diet. No swallowing difficulties. Denies problems
with nausea/vomiting, heartburn, or food intolerances. Regular diet. No recent change in weight. Denies chronic diarrhea, but has selflimiting episodes of diarrhea which he attributes to stress. Also reports episodic problems with hemorrhoids with blood on toilet paper and streaking of passage of hard stool. States currently has a couple small hemorrhoids with no bleeding. Denies history of jaundice, gall bladder, or liver disease. Genitourinary Denies urinary frequency, hesitancy, incontinence, or burning with urination. History of passing 5mm kidney stone 2007. In a long-term monogamous relationship. Denies sexual issues. Metabolic/Hematologic Denies thyroid problems, heat/cold intolerance, excessive hunger, thirst, or history of diabetes. Denies concerning bruising, ease of bleeding. No history of blood transfusions. Psychiatric Denies trouble concentrating, nervousness, anxiety, or panic attack. Denies difficulty falling or staying asleep. Occasional (once/week) getting out of bed earlier than waking time to urinate (associated with drinking fluids at night). Denies mood changes, hearing voices, frequent unhappiness, or desire to harm self or others. Denies nightmares, memory loss, or excessive life stresses. No recent deaths in family or close friends. Musculoskeletal Right ankle fracture (football, non-displaced) 1991. Occasional pain both knees, which he attributes to years of playing sports and not to a traumatic event. Denies other orthopedic injury or arthralgia. Neurologic Denies history of stroke, seizures or frequent/incapacitating headache. Denies tremors. Objective General Appearance 50 year-old male who is awake, alert, and cooperative. Clothing is well kept and appropriate for season. He is oriented to person, place, and time and answers all questions appropriately. Appears stated age, appears to be healthy, and does not appear to be in any acute distress. Vitals BP Right arm sitting. 152/92 HR 72 RR 16 Sa02 99% on room air
Tympanic temp 98.7 Head Normocephalic, short cut hair clean with fine texture. Scalp with no lesions, tenderness. TMJ full ROM without clicks o pain bilaterally. No frontal or maxillary sinus tenderness. Eyes Symmetrical, sclera white, conjunctiva pink. No drainage. PERLA 3/2. Fundoscopy (without pharmacologic mydriasis): red reflex present, no hemorrhages, lens opacities, disk cupping, papillidema, optic vessels appreciated 2:3 AV ratio. Visual acuity deferred. Ears External ear, no lesions, masses, drainage, or tenderness. CN I grossly intact. Otoscopic exam: TMs pearly grey with + cone of light, no bulging, no erythema, landmarks appreciated bilaterally. Nose No nasal flaring. Septum midline, turbinates pink and moist. No lesions, polyps, or nasal discharge bilaterally. Throat and Mouth Membranes pink/moist. Uvula is midline, tonsils at pillars, no redness or exudates. Neck Trachea midline. Thyroid and lymph nodes not palpable. Breasts Inspection: no gynecomastia, nipples symmetrical, everted, no drainage. Palpation: Breasts/axilla node palpation deferred. Heart No JVD at 90 degrees. Carotids not assessed. S1 best at apex. S2 best at base. No extra sounds. Thorax and Back No abnormal curvatures. Symmetrical expansion with respiration Lungs Lung fields not palpated/percussed. Anterior and Posterior lung fields clear to auscultation. Abdomen Round and non-distended with no scars, striae. No abdominal tenderness to palpation. Liver and spleen not palpable. Normoactive tympanic bowel sounds x 4, no abdominal bruits. Extremities (Upper) Nails without cyanosis or clubbing. Muscles well developed. Distal pulses +2. Capillary refill < 3 seconds. Full active ROM. (Lower) Nails without cyanosis or clubbing. Muscles well developed. Distal pulses +2. Capillary refill < 3 seconds. Full active ROM. Hair
growth + great toes bilaterally. Negative Homan’s. Skin Color consistent with race. Warm, dry, intact with good turgor. No peripheral/central cyanosis. No obvious rashes. Multiple small (<0.5 cm) flat hyperpigmented (brown) lesions on abdomen, chest, back, upper extremities, and neck (several with irregular borders). Lymph Nodes Not palpable in head or neck or axilla or groin Neurologic: Mental status: Awake, alert, oriented to person, place, and time. No confusion, anxiety, or agitation noted. Cranial Nerves: II, III PERLA, + consensual movement, + accommodation II, IV, and VI: EOM intact Remaining Cranial Nerves: CN I not assessed. CN V and CN VII – XII grossly intact. Motor System: Muscle strength 5/5 in all extremities bilaterally. Gait steady w/o ataxia. Finger-to-nose, Rhomberg, heel to shin and pronator drift all performed bilaterally without deficit. Sensory: Sharp, dull, light in all extremities tested without deficit. Reflexes: Triceps 2+ 2+. Biceps 2+ 2+, Brachioradialis 2+ 2+, Patellar 2+ 2+, Ankle 1+ 1+. Babinski not assessed. Genitals Not examined Rectal Not examined Labs: TSH, T3, T4, BMP, CBC, HA1C, PSA (all wnl). Assessment 1) 2) 3) 4) 5) Essential stage 1 hypertension Multiple congenital/dysplastic nevi Hemorrhoids Seasonal allergic rhinitis Occasional non-bloody diarrhea of unknown etiology
Plan 1) Three day BP check with plan to initiate ACEI if remains elevated 2) Dermatology referral for evaluation of multiple hyperpigmented skin lesions 3) Discussed importance of colon cancer screening colonoscopy and GI referral for hemorrhoids, episodic diarrhea. Discussed use of procedural anesthesia options. GI referral placed which will be good for six months if patient changes mind. 4) azelastome nasal, 1-2 sprays/nostril bid prn during allergy season. 5) Consider ASA 81mg po QD after cleared by GI
NORTHERN ARIZONA UNIVERSITY SCHOOL OF NURSING FAMILY NURSE PRACTITIONER PROGRAM NUR 661, Spring 2011 Self-Analysis A completed self-analysis will accompany each SOAP note that you turn in. The self-analysis will address the patient contact that is the topic of the SOAP note and will address your analysis of how you are doing overall in the clinical experience. Address the following areas: 1. Clinical Decision Making: how well did you think you did in your clinical decision making? What worked/what didn’t work? For the rest of the semester (SOAPs 5, 6 and 7), please address the following: a) what are 4 common differential diagnoses that you considered on this patient? What subjective and objective data helped you to rule-in or rule-out each of these diagnoses; and b) what are 2 “zebra” differential diagnoses that you consider? What subjective and objective data helped you to rule-in or ruleout each of these? Essential hypertension: Secondary hypertension Congenital/dysplastic nevi: Melanoma Lentigo Hemorrhoids: Rectal polyps Rectal fissures Lower GI Bleed I ruled out secondary hypertension with this patient; there is no indication of endocrine or renal dysfunction (clinical presentation, ROS, exam, labs). Secondary hypertension is normally caused by: coarctation of aorta (Zebras), Cushing’s, diabetes, pheochromocytoma (another Zebra, but he has no tachycardia, nervousness, palpitations, sweating or other sympathetic/adrenergic symptoms) , and drugs such as antidepressants, appetite suppressants, glucocorticoids, and MAOIs. I do want to rule out “white coat hypertension” so I will ask patient to check BP in out of clinic environments. He is not pregnant so I can rule out pre-eclampsia. The main concern with his skin lesions is the possibility of malignancy. His lesions are concerning and should be evaluated and biopsied for a definitive diagnosis by a dermatologist.
The patient gave a good description of his hemorrhoids and does not have any other GI symptoms (lower GI bleed). He does associate the bright blood with passage of hard stool so a rectal fissure could certainly be the cause. Either way, I really want this patient to see a GI specialist for additional work-up and cancer screening colonoscopy. 2. Use of PDA: how did you use PDA to enhance your clinical decision making and incorporate evidence-based, point-of-care information into the decision making process? I used the PDA to run through some of the differentials (primary hypertension vs secondary) and to research some of the Zebras (pheochromocytoma). I also ran through the U.S. Preventive Services Task Force’s application to nail down preventive screening interventions (for this patient, SDT screening but he is in a long-term monogamous relationship, ASA prevention, lipids, hypertension screening). 3. Interaction, Communication and Collaboration with the Patient/Family This patient was a good historian with an uncomplicated med/surgical history. The physician and I both spent time with this patient reviewing the importance of a cancer screening colonoscopy, but he refuses the procedure because he does not “like the idea of anesthesia”. We both spent additional time discussing the anesthetics and sedative agents used for this procedure (very short acting, very few side effects, rapid clearing of effects, no ET tube, etc). We did put in a referral, which will be good for 6 months if he changes his mind. We also tied the fact that the GI consult is needed for eval of his diarrhea as well as his hemorrhoids and that we would hold starting ASA therapy for his heart health until he kicks this can further down the road. 4. Interaction, Communication and Collaboration with Your Preceptor (and others pertinent to the process) 5. Additional Self-Reflections: What did you learn from this experience? Was the learning important for you? Why or why not? What did you learn/observe about yourself this week? How did you advocate for yourself? What do you believe about what you learned this week? How will you transfer the knowledge and learning you gained to other situation? Also address, how well you were able to address psycho social, cultural, and/or family-related issues, any ethical/legal issues, etc. with the patient. I need to discuss why my preceptor deferred doing a rectal exam (has hemorrhoids), and prostate exam, or genital exam for this 50 year-old. My female preceptor is very thorough doing breast exams, genital exams (but again
no rectal exams) on her female patients. This may be a cultural issue with my preceptor, but I wonder how she got through med school (it was a foreign school however…so there may be something there). I’d appreciate pointers on this. Please be specific and insightful. We are looking for depth and breadth of selfanalysis and self-reflection. Add additional pages as needed. Reference: Gutierrez, K. (2008). Pharmacotherapeutics: clinical reasoning in primary care (2nd ed.). St. Louis, Mo: Saunders Elsevier.
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