NSG6420 Week 4 SOAP

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School

South University, Savannah *

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Course

6420

Subject

Medicine

Date

Feb 20, 2024

Type

docx

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Uploaded by BailiffCloverStork22

SOAP NOTE Student Name: Course: NSG6420 Name: Date: Time: 1115 Ethnicity: White Age: 39 Sex: M SUBJECTIVE CC: “I have been having pain/burning in my chest and sour taste in my mouth” HPI: The patient is a 39-year-old white male who presents with a chief complaint of epigastric pain and a sour taste in his mouth. He reports that the pain is intermittent and often occurs after meals, with a duration of approximately two months. The patient describes the pain as a burning sensation and rates its intensity as moderate. He denies any radiation of pain and reports occasional regurgitation of stomach contents with a sour taste. No associated symptoms such as dysphagia, weight loss, or changes in bowel habits are reported. Medications: (list with reason for med ) None PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas: Denies Hospitalizations/Surgeries- Appendectomy Family History M: Alive- Type 2 Diabetes, hyperlipidemia MGM: Deceased MGF: Deceased- Colon Cancer F: Alive- hypertension

PGM: Alive PGF Alive Social History The 39-year-old white male is currently single and resides in an apartment, having worked in an insurance office for 10 years. He completed his education up to an associates degree. The patient has a supportive social network and engages in pickle ball for exercise and yoga for relaxation. There is no history of tobacco or illicit drug use, and he reports minimal alcohol consumption without any abuse . ROS General Patient denies nights sweats and fatigue Cardiovascular Denies any chest pain or shortness of breath. Skin No rash, lesions, or other skin abnormalities Respiratory Denies shortness of breath, reports chest congestion, productive cough Eyes Denies any visual changes, complains of pain behind bilateral eyes Gastrointestinal Reports heart burn and regurgitation of food, Denies abdominal pain, nausea, vomiting or diarrhea Ears Denies ear pain or hearing loss Genitourinary/Gynecological Denies discharge, dysuria hematuria. Nose/Mouth/Throat Musculoskeletal

Reports persistent sour taste in the mouth. Denies loss of smell, sore throat, reports nasal discharge and congestion Denies pain to extremities or difficulty ambulating Breast Denies pain or discomfort Neurological Denies syncope, seizures, headache, or dizziness Heme/Lymph/Endo Denies bleeding, no enlarged lymph nodes Psychiatric Denies depression, anxiety, SI or sleeping difficulty OBJECTIVE Weight 77kg BMI 24.29 Temp 37.1 BP 136/78 Height 5’10 Pulse 65 Resp 18 General Appearance The 39-year-old well-mannered white male presents with a neat and groomed appearance. He maintains appropriate eye contact, exhibits calm demeanor, and cooperates effectively during the examination, demonstrating an overall composed and respectful attitude. Skin Skin in clean, dry and intact. HEENT Head is normocephalic, atraumatic. Eyes: Pupils are equal, round, and reactive to light, vision grossly normal. Ears: Canals patent. Bilateral tympanic membranes clear, landmarks easily visualized. Nose: Nasal mucosa red; normal turbinates. No septal deviation. Tenderness present on palpation at the sinus maxillary and frontal sinus Neck: Supple. Full ROM; trachea midline. Mouth/throat: Oral mucosa is moist and pink. Teeth are in good repair . Pharynx appears red without any erythema or exudate. The uvula is midline. The tonsils are without enlargement or evidence of inflammation. Cardiovascular Normal rhythm and rate, characterized by clearly audible S1 and S2 heart sounds. No additional auscultatory findings, including murmurs, rubs, or clicks, are noted. Absence of edema is observed, and pulses are uniformly assessed as 3+. Capillary refill time is measured at a brisk two seconds. Respiratory Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal Gastrointestinal Abdomen is slim and symmetrical, soft, non-tender, no guarding or rebound tenderness, bowel sounds present in all four quadrants Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin .

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