Inguinal Hernia
NSG 6020 iHuman Soap Note – 50-Yr Old Patient with Left Groin Pain: Inguinal Hernia
NSG 6020 iHuman Soap Note – 50-Yr Old Patient
SOAP NOTE
Identify: Mr. B. Date: Could 27, 2018 Time: 2:44PM
Age: 50 years outdated Intercourse: Male
SUBJECTIVE
CC:
“I’ve obtained this horrible ache in my left groin, doc. Please do one thing. It’s killing me.”
HPI:
Seen and examined Mr. B, a 50-year outdated Caucasian Male offered within the clinic for left groin ache 10/10.
Has continual Hypertension that’s managed with Lisinopril taken each day.
Onset – Six hour in the past.
Location – left groin ache radiating to scrotal space
Period – Fixed and getting worse
Attribute – Sharp, stabbing ache that seems like “tearing” inside
Aggravating components: Standing and bending makes it worse
Relieving components: No different components discovered to useful right now.
Therapy – Search medical consideration
Medicines:
Lisinopril 20mg each day for Hypertension
PMH
Allergic reactions: No recognized Allergic reactions
Medicine Intolerances: None
Power Diseases/Main traumas: Hypertension
Hospitalizations/Surgical procedures
Extracorporeal Shockwave Lithotripsy – years in the past
Household Historical past
Mom – Hypothyroidism, Breast Most cancers
Father – Hypertension, CAD, prostate most cancers
Signifies Patient
Dwelling Male
Dwelling Feminine
Nostril/Mouth/Throat
Denies having any lesions, plenty and tenderness. Additionally denies problem of listening to, vertigo and throat ache.
Musculoskeletal
Denies weak spot, stiffness and joint ache
Breast
Denies rashes, bruising, sores, lumps, dryness and coloration adjustments.
Neurological
Denies numbness and tingling, denies having imaginative and prescient or listening to issues, tremors, and gait instability.
Heme/Lymph/Endo
Denies straightforward bruising and bleeding, Denies warmth or chilly intolerance, and denies having swollen lymph nodes.
Psychiatric
Denies anxiousness, melancholy, problem sleeping and suicidal ideation.
OBJECTIVE
Weight 180 lbs BMI 24.four Temp 99.zero BP 170/94
Peak 6’zero” Pulse 130 – common Resp 18
Common Look
Seen and examined Mr. B, 50-year outdated Caucasian male complains left groin fixed ache. Seems to be cellular and nice however seems to be annoyed from fixed ache. Alert and oriented x four, solutions all questions appropriately and really cooperative.
Pores and skin
Intact, diaphoretic with no bruising, lesions, rashes or discoloration famous. No cyanosis or clubbing famous. No seen scars noticed. Pores and skin coloration is suitable for ethnicity.
HEENT
· Normocephalic
· Conjunctiva pink, sclerae white, no jaundice, free from drainage, PERRLA. 20/20 imaginative and prescient
· Ears non-tender, no swelling and free from drainage
· Nostril: nasal mucosa moist with out drainage, septum midline, free from swelling and lesions
· Throat: free from lesions and never enlarged
· Neck: Trachea is midline, non-palpable thyroid and lymph nodes, neck supple with no plenty or tenderness.
Cardiovascular
S1, S2 with common fee and rhythm. No additional sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses three+ all through. No edema.
Respiratory
Symmetrical chest enlargement. Respirations even and unlabored, breath sounds clear upon ausculatation bilaterally. No wheeing, rhonchi, or stridor famous. No elevated tactile fremitus.
Gastrointestinal
Stomach flat, tender, non-distended, Bowel sounds current on all quadrants. Stomach tympanic with percussion, Non-tender when palpated and no hepatosplenomegaly. Mildly swollen, indurated left groin inflicting rigidity to overlying pores and skin.
Breast
-Regular, non-tender. No plenty, lumps, deformities, ulcerations or discharge.
Genitourinary
-left groin visibly swollen and indurated upon palpation. Proper groin regular.
-tenderness current on the left inguinal canal ; proper inguinal canal regular
-left scrotal space swollen
– testicles are regular in measurement and non-tender upon palpation
-Regular Penile shaft, with out lesions or discharge
-No flank tenderness to percussion
Assessment: For Inguinal Hernia
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NSG 6020 Week 5 SOAP Note Task
SOAP Note
Every week you might be required to enter your affected person encounters into CORE. Your college will likely be checking to make sure you are seeing the best quantity and mixture of sufferers for an excellent studying expertise. Starting in Week 5, you have to to incorporate one full SOAP observe every week by Week 9 for a complete of 5 full SOAP notes for this course utilizing this SOAP observe template. The SOAP observe ought to be associated to the content material coated on this week, and the finished SOAP observe ought to be submitted to the Submissions Space. When submitting your observe, remember to embody the reference quantity from CORE the place you entered this particular affected person’s case entry.
Submission Particulars:
By the due date assigned, enter your affected person encounters into CORE and full a minimum of one SOAP observe within the template offered.
Identify your SOAP observe doc SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.
Embody the reference quantity from CORE in your doc.
Submit your doc to the Submissions Space by the due date assigned.
Week 6 SOAP Note Task
SOAP Note
Every week you might be required to enter your affected person encounters into CORE. Your college will likely be checking to make sure you are seeing the best quantity and mixture of sufferers for an excellent studying expertise. Starting in Week 5, you have to to incorporate one full SOAP observe every week by Week 9 for a complete of 5 full SOAP notes for this course utilizing this SOAP observe template. The SOAP observe ought to be associated to the content material coated on this week, and the finished SOAP observe ought to be submitted to the Submission Space. When submitting your observe, remember to embody the reference quantity from CORE the place you entered this particular affected person’s case entry.
Submission Particulars:
By the due date assigned, enter your affected person encounters into CORE and full a minimum of one SOAP observe within the template offered.
Identify your SOAP observe doc SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.
Embody the reference quantity from CORE in your doc.
Submit your doc to the Submissions Space by the due date assigned.
Week 6 Bodily Examination Video and Write Up Task
Full Well being Historical past and Bodily Assessment Write-Up Presentation
This project consists of full head to toe bodily whereas being videoed. Additionally, you will want to finish a written project of your findings. Overview the Expanded rubric to notice how you can be graded on this project.
Week 7 SOAP Note Task
Every week you might be required to enter your affected person encounters into CORE. Your college will likely be checking to make sure you are seeing the best quantity and mixture of sufferers for an excellent studying expertise. Starting in Week 5, you have to to incorporate one full SOAP observe every week by Week 9 for a complete of 5 full SOAP notes for this course utilizing this SOAP observe template. The SOAP observe ought to be associated to the content material coated on this week, and the finished SOAP observe ought to be submitted to the Submissions Space. When submitting your observe, remember to embody the reference quantity from CORE the place you entered this particular affected person’s case entry.
Submission Particulars:
By the due date assigned, enter your affected person encounters into CORE and full a minimum of one SOAP observe within the template offered.
Identify your SOAP observe doc SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.
Embody the reference quantity from CORE in your doc.
Submit your doc to the Submissions Space by the due date assigned.
Week eight SOAP Note Task
SOAP Note
Every week you might be required to enter your affected person encounters into CORE. Your college will likely be checking to make sure you are seeing the best quantity and mixture of sufferers for an excellent studying expertise. Starting in Week 5, you have to to incorporate one full SOAP observe every week by Week 9 for a complete of 5 full SOAP notes for this course utilizing this SOAP observe template. The SOAP observe ought to be associated to the content material coated on this week, and the finished SOAP observe ought to be submitted to the Submissions Space. When submitting your observe, remember to embody the reference quantity from CORE the place you entered this particular affected person’s case entry.
Submission Particulars:
By the due date assigned, enter your affected person encounters into CORE and full a minimum of one SOAP observe within the template offered.
Identify your SOAP observe doc SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.
Embody the reference quantity from CORE in your doc.
Submit your doc to the Submissions Space by the due date assigned.
Week 9 SOAP Note Task
SOAP NOTE
Every week you might be required to enter your affected person encounters into CORE. Your college will likely be checking to make sure you are seeing the best quantity and mixture of sufferers for an excellent studying expertise. Starting in Week 5, you have to to incorporate one full SOAP observe every week by Week 9 for a complete of 5 full SOAP notes for this course utilizing this SOAP observe template. The SOAP observe ought to be associated to the content material coated on this week, and the finished SOAP observe ought to be submitted to the Submissions Space. When submitting your observe, remember to embody the reference quantity from CORE the place you entered this particular affected person’s case entry.
Submission Particulars:
By the due date assigned enter your affected person encounters into CORE and full a minimum of one SOAP observe within the template offered.
Identify your SOAP observe doc SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.
Embody the reference quantity from CORE in your doc.
Submit your doc to the Submissions Space by the due date assigned.
