SOAP WEEK 4
Patrick Smith Age 42
Subjective
Chief complaint: ―I am in a lot of pain in my back and abdomen‖
History of present illness (HPI):
O: Onset- 5 am
L: Location—initially pain begin on the side of his back; and now there is also pain in his
stomach
D: Duration-intermittent pain that comes in waves
C: Characteristics/Associated symptoms- throbbing, feels nauseated, urinary frequency, sweaty,
pain that and at times shoots down to the groin
A: Aggravating factors -sitting in the office
R: relieving factors- nothing
T: Treatments- used Tums and they were not effective, nor was position changes
S: Severity- rated 8/10
Past Medical History- NKDA. Immunizations UTD. Describes health as good. Has hay fever
and psoriasis, medication which was given at last visit worked, not using at this time. No
previous back injuries. No daily medications. No herbal medication use. Had his appendix out at
age 10. Previous hospitalization for broken leg requiring traction at age 8.
Family History- Parents are deceased. Mother died at age 51 from a brain tumor and father died
age 53 leukemia. Has one brother in good health.
Social History- Married, has four children. Lives with his immediate family and in-laws. Works
full time as a plumber. Work has been so busy no time lately for regular exercise. Smokes
cigarettes, a pack a day. No ETOH or illicit drug use. Sleeps 5-6 hours a night.
Review of Systems:
Neurologic: no report of further headaches, denies dizziness
Head/Eyes/Ears/Nose/Mouth/Throat: No report of nasal congestion, or discharge, denies lymph
node enlargement
Integumentary: not reviewed
Cardiovascular: denies palpitations
Respiratory: No report of wheezing or shortness of breath with rest
, Genitourinary: not reviewed
Gastrointestinal: No reports of heartburn, or indigestion, endorses nausea
Musculoskeletal: not reviewed
Hematologic: not reviewed
Endocrine: not reviewed
Objective
VS T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%. 5 feet 9 inches weight: 195 pounds
BMI 28.8
Urinalysis: Positive WBCs, Small blood. Trace protein, pH 7.0 specific gravity 1.030, negative
nitrites, negative ketones, negative glucose
CBC: WBC 6000 mm3 RBC 5 million Hbg 15g Hct 46% MCV 90 fL MCHC 35 g/dL
Ultrasound report: 5mm smooth round calculus is noted at the junction of the ureter and the
bladder
Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution
throughout scalp. Sclera clear, conjunctiva white. Tympanic membranes gray and intact with
light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist,
no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple.
No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation
bilaterally. Respirations unlabored. Abdomen appears slightly distended, symmetric with no
visible masses. RLQ scar noted. Decreased bowel sounds noted. No vascular sounds. Tympany
noted in all four quadrants on percussion. Abdomen is soft, no organomegaly, no masses or
tenderness. Positive CVAT on right side.
Assessment:
Urolithiasis (ICD 10: N21.9)- Frassetto and Kohlstadt (2011) report that plaques are composed
of calcium phosphate/apatite deposits, localized to the basement membrane of the thin loop of
Henle and extending into the papillary interstitium. When these plaques form, they erode through
the urothelium and constitute a stable, anchored surface on which calcium oxalate crystals can
nucleate and grow as attached stones (Frassetto & Kohlstadt, 2011). This patient is believed to
have nephrolithiasis as he complains of acute severe flank pain, nausea, urinary frequency, groin
pain, and costovertebral angle tenderness. In addition, the ultrasonographer has stated the patient
has a 5mm stone which is present at the junction of the ureter and the bladder. The location of the
stone is known as ureterovesical junction. Lastly, the urinalysis identified hematuria to further
support the diagnosis.
Patrick Smith Age 42
Subjective
Chief complaint: ―I am in a lot of pain in my back and abdomen‖
History of present illness (HPI):
O: Onset- 5 am
L: Location—initially pain begin on the side of his back; and now there is also pain in his
stomach
D: Duration-intermittent pain that comes in waves
C: Characteristics/Associated symptoms- throbbing, feels nauseated, urinary frequency, sweaty,
pain that and at times shoots down to the groin
A: Aggravating factors -sitting in the office
R: relieving factors- nothing
T: Treatments- used Tums and they were not effective, nor was position changes
S: Severity- rated 8/10
Past Medical History- NKDA. Immunizations UTD. Describes health as good. Has hay fever
and psoriasis, medication which was given at last visit worked, not using at this time. No
previous back injuries. No daily medications. No herbal medication use. Had his appendix out at
age 10. Previous hospitalization for broken leg requiring traction at age 8.
Family History- Parents are deceased. Mother died at age 51 from a brain tumor and father died
age 53 leukemia. Has one brother in good health.
Social History- Married, has four children. Lives with his immediate family and in-laws. Works
full time as a plumber. Work has been so busy no time lately for regular exercise. Smokes
cigarettes, a pack a day. No ETOH or illicit drug use. Sleeps 5-6 hours a night.
Review of Systems:
Neurologic: no report of further headaches, denies dizziness
Head/Eyes/Ears/Nose/Mouth/Throat: No report of nasal congestion, or discharge, denies lymph
node enlargement
Integumentary: not reviewed
Cardiovascular: denies palpitations
Respiratory: No report of wheezing or shortness of breath with rest
, Genitourinary: not reviewed
Gastrointestinal: No reports of heartburn, or indigestion, endorses nausea
Musculoskeletal: not reviewed
Hematologic: not reviewed
Endocrine: not reviewed
Objective
VS T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%. 5 feet 9 inches weight: 195 pounds
BMI 28.8
Urinalysis: Positive WBCs, Small blood. Trace protein, pH 7.0 specific gravity 1.030, negative
nitrites, negative ketones, negative glucose
CBC: WBC 6000 mm3 RBC 5 million Hbg 15g Hct 46% MCV 90 fL MCHC 35 g/dL
Ultrasound report: 5mm smooth round calculus is noted at the junction of the ureter and the
bladder
Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution
throughout scalp. Sclera clear, conjunctiva white. Tympanic membranes gray and intact with
light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist,
no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple.
No lymphadenopathy. Thyroid midline, small and firm without palpable masses.
Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation
bilaterally. Respirations unlabored. Abdomen appears slightly distended, symmetric with no
visible masses. RLQ scar noted. Decreased bowel sounds noted. No vascular sounds. Tympany
noted in all four quadrants on percussion. Abdomen is soft, no organomegaly, no masses or
tenderness. Positive CVAT on right side.
Assessment:
Urolithiasis (ICD 10: N21.9)- Frassetto and Kohlstadt (2011) report that plaques are composed
of calcium phosphate/apatite deposits, localized to the basement membrane of the thin loop of
Henle and extending into the papillary interstitium. When these plaques form, they erode through
the urothelium and constitute a stable, anchored surface on which calcium oxalate crystals can
nucleate and grow as attached stones (Frassetto & Kohlstadt, 2011). This patient is believed to
have nephrolithiasis as he complains of acute severe flank pain, nausea, urinary frequency, groin
pain, and costovertebral angle tenderness. In addition, the ultrasonographer has stated the patient
has a 5mm stone which is present at the junction of the ureter and the bladder. The location of the
stone is known as ureterovesical junction. Lastly, the urinalysis identified hematuria to further
support the diagnosis.
