Physical Assessment and Diagnostic Reasoning

Advanced Physical Assessment and Diagnostic Reasoning SOAP Note Assignment

Instructions:

1. Read the following SOAP note about “J.H.” He recently moved to the area and is at your family practice clinic to establish care with a new provider – YOU!
2. Answer the questions on a separate Word document. Use the Documentation Guide for Chronic Conditions as a guide.
3. Submit your work on Sakai under “Assignment #1”.

Objectives:

1. Identify components of system-based physical examinations.
2. Critique SOAP notes for missing history elements.
3. Identify the pathophysiology of an identified disease process and its relationship to assessment findings for individual patients.
4. Differentiate pertinent findings in a patient’s health history and physical examination.
5. Identify sources for clinical decision making for use in the assessment of patients.

SOAP Note:
Date
09/14/17

Pt Identity
J.H., 58 y/o White male, seems reliable. Prior medical records not available.

Chief Concern
“I need a new doctor.”

History of Present Illness
No complaints. Last provider appointment 6 months ago.

Past Medical History
Adult Illnesses
HTN for “most of my adult life,” no active treatment. OA bilateral knees “for about 15 years,” controlled.
Hypothyroidism “diagnosed a couple of years ago,” controlled. Denies CA, CAD, CVA, HLD, and DM.

Health Maintenance

No vaccine records available at visit. Refuses seasonal influenza vaccine. Unable to recall date of last tetanus vaccine.
Colonoscopy 6 years ago, reports “they didn’t find anything.”
Has not had EKG, CXR, echo, TB test, lipid panel, or hemoglobin A1c checked. Last eye exam 2-3 years ago. Last dental exam < 6 months ago. No consistent exercise. Eats >50% processed foods, but reports eating “fruits and vegetables when I can,” 3+ sodas per day, and up to 2 cups of coffee each morning.
Regularly uses seat belts, sunblock, and has working smoke detectors.

Childhood Illnesses
Denies measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, polio, and congenital disease.

Surgical History
Bilateral TKR (Rt 2014, Lt 2015), no complications. Tonsillectomy, age 8-9, no complications.

Accidents/Injuries Denies.

Hospitalizations
Post-TKR in 2014 and 2015, 2-3 days each. Post-tonsillectomy in late 1960’s, ~5 days.

Psychosocial History
Divorced, lives alone, 3 adult children living out-of-state. Completed bachelor’s degree in management. Denies military service. Methodist affiliation. Has not been sexually active since divorce 5 years ago.
Works full-time desk job at steel mill, no heavy lifting required; sedentary (sits for 5+ hours at a time), 12-16 hour shifts, 5-6 days/week. Reports having several close friends from work.
Regular hobbies include bowling and woodworking.
Former smoker (30 pack-years), quit 5 years ago. Denies alcohol and other drug use.

Allergies
Penicillins (rash, itching). Denies environmental and food allergies.

Current Medications
Levothyroxine 0.125 mg daily. Last dose today.
Acetaminophen 1000 mg 1-2 times/day PRN for knee pain. Last dose yesterday afternoon. Reports having prescription for “a water pill” that he stopped taking after 2 weeks due to nocturia and frequency. Last dose ~4 months ago.

Review of Systems

General: Denies weight change, fever, chills, night sweats, fatigue, weakness, and changes in appetite.
Skin: Denies rashes, ulcerations, dryness, flaking, excessive sweating, and changes in moles. HEENT: Head: Denies HA, head injury, dizziness, and lightheadedness. Eyes: Denies eye pain, redness, excessive tearing, double or blurred vision spots, flashing lights, and the use of eyeglasses or contact lenses. Ears: Denies ear pain, tinnitus, vertigo, discharge, and use of hearing aids. Nose and Sinuses: Denies frequent colds, nasal stuffiness, drainage, itching, nosebleeds, and sinus pain. Mouth and Throat: Denies bleeding gums, sore throat, dry mouth, hoarseness, and use of dentures.
Neck: Denies swollen glands, goiter, lumps, pain, or stiffness.
Pulmonary: Denies cough, dyspnea, increased sputum production, hemoptysis, snoring, and wheezing.
Cardiovascular: Denies chest pain, palpitations, orthopnea, PND, known heart murmurs, edema, intermittent claudication, leg cramps, and varicose veins.
GI: Denies trouble swallowing, N/V, indigestion, abdominal pain, constipation, diarrhea, blood in stool, and hemorrhoids. Last BM yesterday, appearance usual for patient.
GU: Reports erectile dysfunction x3 years, has not discussed w/ a provider. Reports urine frequency, reduced caliber, and occasional post-void dribbling of small amounts of urine x4-5 weeks, has not discussed w/ a provider. Denies dysuria, urgency, nocturia, burning w/ urination, incontinence, flank pain, suprapubic pain, hernias, ulcerations, drainage, scrotal pain, and hematuria. Has no concerns about STIs.
MS: Reports mild to moderate cramps in left calf at night over the last 3 months that release with massage and bearing weight; last episode 2 weeks ago; “probably because I don’t drink enough water.” Reports mild soreness in bilateral knees “almost daily after work, probably because of my arthritis,” accompanied by swelling and stiffness, relieved by rest and acetaminophen. Otherwise denies joint/muscle pain.
Neuro: Denies paresthesia, tremor, seizures, and changes in gait/strength/balance/coordination. Denies problems with memory or speech. Hem: Denies easy bruising or bleeding, pallor, and past transfusions.
Endo: Reports feeling thirsty and having to urinate more often, which has increased over the last 3-4 weeks; drinks 10-12 glasses of liquid per day and urinates every ~2 hours. Denies excessive sweating, heat or cold intolerance, and increased hunger.
Psych: Reports feeling lonely “sometimes.” Coping methods include TV, talking with friends, bowling or playing golf “when I have time.” Denies feeling depressed, nervous, or anxious.

PHYSICAL EXAM
Constitutional: Appears well-groomed, well-nourished, and well-developed. Sitting comfortably in exam room chair. T 97.4F (oral), HR 84, RR 18, BP 138/76 (right). BMI 42.
Skin: Erythematous dry pruritic rash covering flexor surface of left elbow w/ superficial abrasions from scratching; no edema, drainage, or heat present. Otherwise, exposed skin is smooth, free of lesions, bruising, tattoos, and piercings. Several nevi noted on forearms and forehead. Hair thinning at crown and temples. No facial hair. Nails trimmed and in good condition. Healed surgical scars on medial aspects of bilateral knees.
Head: Normocephalic, atraumatic. No masses, lesions, or scalp tenderness.

Eyes: Visual acuity not examined at this visit. Visual fields full by confrontation. Conjunctivae clear, sclera white. EOM intact, equal convergence, no nystagmus. Disc margins sharp without hemorrhages or exudates, no A-V nicking. Wearing prescription lenses.
Ears: Whisper test negative. Canals clear with average hair distribution, no erythema or edema. TM’s pearly gray, landmarks and cones in usual positions. Weber midline. AC > BC. Nose/Sinuses: Mucosa pink, moist without lesions or drainage. Nasal septum midline without perforation.
Mouth/Throat: Lips and gums pink, moist without lesions. Teeth in good condition with evidence of cavity filling on bilateral lower molars. Tongue pink, moist, midline without lesions. Salivary glands non-palpable/non-tender. Uvula midline, rises with vocalization. Oropharynx pink and moist, no exudate. Tonsils absent. Jaw opens and closes smoothly.
Neck: Full ROM w/o pain. Trachea midline.
Lungs/Thorax: Thorax symmetric with good excursion. Rate regular and unlabored. No accessory muscle use. Lung sounds clear and equal bilat. Diaphragmatic expansion symmetrical. No chest wall lesions, masses, or tenderness. Resonant in all lung fields. Nail beds pink w/o clubbing.
Cardiovascular: Regular rate/rhythm w/o clicks, gallops, rubs, S3, S4, or murmurs. Carotid upstrokes brisk, pulses 2+ bilat w/o bruit.
Abdomen: Obese, soft, symmetrical, w/o masses, lesions, or hernia. Bowel sounds normoactive x4 quadrants. Resonant w/ gastric tympany. No tenderness or rigidity on light and deep palpation. No renal/aortic/iliac bruits. Liver edge smooth, palpable 1 cm below RCM. Spleen and kidneys not examined. No CVA tenderness.
GU/Rectal: Circumcised male. No penile discharge or lesions. No scrotal swelling, discoloration, or masses. No inguinal hernias. Rectal exam not performed.
Peripheral Vascular: Radial, femoral, and popliteal pulses 2+ bilat. Pedal pulses 1+ bilat. Trace pitting edema bilat ankles. Legs are hairless and shiny. No varicosities, stasis pigmentation, or ulcers.
Musculoskeletal: Full active ROM all joints w/o pain, swelling, or deformity. Strength 5+ throughout. No tremor. Gait smooth with increased side-to-side sway.
Neuro: Right-hand dominant. Alert and cooperative. Thoughts coherent, oriented to person, place, and time. Cranial nerves II-XII intact. Good muscle bulk and tone, strength 5/5 throughout. Rapid alternating movement of fingers performed w/o difficulty. Light touch, position, sense, and vibration intact. Patellar reflexes 2+ bilateral. Romberg negative.
Psych: Affect bright and appropriate.

1. Which major section of the patient’s health history is missing from this note? According to your textbook (chapter 3) what information should you include in this section?
2. What are the 9 specific complaints/concerns from his ROS? Choose one of these concerns and identify questions you would ask to explore it further (Hint: Use OLDCARTS or PQRSTU).
3. Towards the end of your visit, your patient remembers that he noticed a rash on his arm. Using the transcript below, how would you document this symptom in his ROS?
   Patient: “Hey, sorry – I forgot. I have one more thing. About a week ago, I noticed this red spot on my arm (points to reddened area on flexor surface of right elbow).
   What do you think that is?

You: “Have you ever had a rash like this before?” Patient: “No.”
You: “Tell me how it showed up – was it all of a sudden like this, or did it get worse over time?”

Patient: “Well, I didn’t notice anything there at all until about a week ago. Since then it has gotten really itchy and more like a bright red. It’s a lot worse at the end of the day when I get home from work.”

You: “How bad is the itching, on a scale from 1-10 with 1 being not itchy and 10 being the itchiest thing you’ve ever felt?”

Patient: “It’s hardly anything, like a 1, when I first wake up. But when I get home from work it’s like a 5 or 6.”

You: “Is there something at work that you think might be aggravating it? Any new chemicals or materials that you are coming into contact with?”

Patient: “Let me think. No, the only thing that’s changed at work is that the air conditioning went out and it’s always like 100 degrees at my desk. I sweat all the time, especially when the afternoon sun comes in my window.”

You: “Do you tend to flex your elbows most of the day, like from typing on a keyboard?”

Patient: “Yeah, especially in the afternoons.”

You: “Does that inner elbow get pretty sweaty most of the time then?” Patient: “Definitely.”
You: “Okay, how about other things you might have been exposed to. Have you been doing any yard work, camping, hiking, handling livestock or pets?”

Patient: “No, none of that.”

You: “Does anything make the itching and redness feel better?”

Patient: “Taking a shower helps. Maybe because I’m able to get this sweat off of me. I haven’t put any creams or anything on it.”

You: “Is there anyone else you know with the same rash?” Patient: “No, I think I’m the only one.”
You: “I know you said you don’t have any allergies to things like dust or tree nuts, but can you think of anything else you might be allergic to?”

Patient: “Not really.”

You: “OK, have a seat and I’ll take a closer look at your rash.”

4. The physical exam of the eyes, nose/sinuses, and neck are each missing a key piece of information. Identify at least 2 missing exam components for each of these systems (Hint: Don’t focus on making up the exam findings – just identify what part of the exam is missing).
5. Choose one of the missing exam components from each system (eyes, nose/sinuses, and neck), and document their “normal” exam findings. Indicate where you found this information in the textbook (include page number) or lecture (include slide number).