ANSWER
This SOAP note is designed for a patient who has a kidney stone and presents with flank pain:
SOAP Note Format
Name of the patient: [Insert Name]
Date: [Insert Date]
Name of Provider: [Insert Your Name]
Subjective (S): CC (Chief Complaint): “I have intermittent, excruciating pain in my right side.”
A 45-year-old man’s HPI (History of Present Illness) includes a sudden onset of intense, severe, and intermittent right flank discomfort that radiates to the groyne. Along with nausea and sporadic vomiting, the discomfort began twelve hours ago. There were no reports of fever. Although the patient reports bloody, dark urine, they deny any appreciable changes in the frequency or urgency of their urination. No prior history of comparable incidents is known.
Past Medical History, or PMH:
Lisinopril-controlled hypertension
No past history of urinary tract infections or kidney stones
Allergies:
No medications:
20 mg of lisinopril each day Family History:
Kidney stones were a history for the father. Social History:
Sedentary lifestyle, occasional alcohol consumption, and nonsmoking
Review of Systems, or ROS:
Hematuria, nausea, and flank pain are all positive.
Negative for severe weight loss, chills, fever, or dysuria
Goal (O):
Vital Signs:
Blood pressure: 135/85 mmHg
HR: 92 beats per minute
RR: 18 breaths per minute
Temperature: 98.6°F
99% SpO₂ on room air
Physical Examination:
General: Pain in the right flank area is causing the patient to appear in severe anguish.
Abdomen: No distension; right flank discomfort; no guarding or rebound tenderness
Genitourinary: No palpable tumours or lesions, normal external genitalia
Cardiovascular: steady beat and pace, no muttering
Respiratory: Both sides provide distinct breath sounds.
Diagnostics, if relevant:
Hematuria is detected by urinalysis; there are no detectable leukocytes or nitrites.
Abdomen/pelvis non-contrast CT scan: Verifies a right ureteral stone measuring 5 mm without hydronephrosis
Evaluation (A):
Principal Diagnosis:
N20.0 Urolithiasis: Various Diagnoses
Pyelonephritis (ruled out because there is no pyuria or fever)
Appendicitis (ruled out due to lack of RLQ discomfort and imaging)
Musculoskeletal pain (less probable in light of imaging results and hematuria)
Plan (P):
1. Diagnostic Examinations:
Continue using serial urinalysis to check for blockage or infection.
2. Drugs:
Pain control: Give 800 mg of ibuprofen every eight hours as needed to treat pain.
Ondansetron 4 mg every 8 hours as needed for nausea is an antiemetic.
Tamsulosin 0.4 mg per day is an alpha-blocker that helps stones pass.
3. Education of Patients:
Encourage the patient to drink more water—at least two to three litres a day—in order to facilitate the passage of stones.
Teach patients to seek medical attention right away if they experience any of the following symptoms: fever, chills, worsening pain, or difficulty urinating.
4. Follow-up:
If symptoms worsen, make an appointment for a follow-up within a week.
If, after four weeks, the stone has not gone away, repeat imaging (KUB or ultrasound).
Signed by the provider: _______________________
____________________________ Date and Time:
If you want any additional changes or clarification, please let me know!
QUESTION
Patient is having flank pain due to a kidney stone.
A SOAP note is a method of documentation employed by healthcare providers to record and communicate patient information in a clear, structured, and in an organized manner. This assignment will provide students with the necessary tools to document patient care effectively, enhance their clinical skills, and prepare them for their roles as competent healthcare providers.
Instructions:
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.
For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
| S = | Subjective data: Patient’s Chief Complaint (CC). |
| O = | Objective data: Including client behavior, physical assessment, vital signs, and meds. |
| A = | Assessment: Diagnosis of the patient’s condition. Include differential diagnosis. |
| P = | Plan: Treatment, diagnostic testing, and follow up |
Submission Instructions:
· Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspellings.
· You must use the template provided. Turnitin will recognize the template and not score against it.
· Your submission will be reviewed for plagiarism through Turnitin.
·