SOAP note

Question 1

1. Subjective

WHAT IS NEXT?

Answer 1

Patient Name: Luke Vandermyde
DOB: 8-5-1993
Date: 5-12-2015
Time: 1:00 PM

Question 2

CC:

Answer 2

“arm pain”

Question 3

HPI:

Answer 3

21 year old male presents with pain radiating down the right arm. Began 2 days ago after a soccer game. The patient remembers no specific injury to the arm . The pain has been increasing in intensity. The pain was 2/10 days ago and is 5/10 today in the office on a 0 to 10 scale with 10 being the worst pain. Patient has tried acetaminophen but it does not alleviate the pain. The pain is described as “knife-like.” The pain begins in the shoulder and courses down the medial portion of the arm to the forearm and medial hand. The patient denies experiences similar symptoms previously. Patient denies any loss of sensation on the right arm. Patient does not have any symptoms on the left arm. Patient denies fever, chills, night sweats, weight loss, weight gain, and fatigue.

Question 4

Meds:

Answer 4

Acetaminophen 50 micrograms two tablets daily by mouth last dose at 9 AM today.

Question 5

Allergies:

Answer 5

Peanuts- rash. Denies drugs and environmental allergies.

Question 6

PMHX:

Answer 6

Patient denies any ongoing medical conditions and denies recent hospitalizations. Patient denies thyroid disease, heart disease, emphysema, cancer, hypertension, asthma, diabetes, and stroke.
Immunizations: reports having had all childhood, tetanus 2014, influenza 9/2014, denies pneumonia.
PSHX: Tonsillectomy- tonsillitis, Mercy 1998, no complications.

Question 7

PSHX:

Answer 7

Tonsillectomy- tonsillitis, Mercy 1998, no complications.

Question 8

FMHX:

Answer 8

Father: 54, alive with hypertension.
Mother: 54, alive with hypertension.
Sister: 25, alive with asthma.
Son: 2, alive and healthy.

Question 9

SOCHX:

Answer 9

Full time student studying medicine. Volunteers at Mercy on the weekends. Single and interested in men. One 8 oz beer every night and 2 8 oz beers every weekend night. Diet is vegetarian. Exercise 3 times a week running for 30 minutes. Denies concerns about sexually transmitted diseases or HIV/AIDS. Denies tobacco, illict drugs, military, recent travel.

Question 10

Vital signs:

Answer 10

T 98.6 F P 80 regular R 14 easy BP 110/60

Question 11

General:

Answer 11

Patient is lying on examine table. Well nourished, pleasant and cooperative.

Question 12

Mental Status:

Answer 12

Alert and oriented to person, place, and time.

Question 13

CN I:

Answer 13

Differentiated separate scents in each nostril.

Question 14

CN II:

Answer 14

Visual acuity 20/30 bilaterally via Rosenbaum. Swinging flashlight revealed appropriate direct and consensual response. Peripheral fields full by confrontation bilaterally.

Question 15

CN III, IV, VI:

Answer 15

Pupils approximately 4 mm, round and symmetric bilaterally. PERLA bilaterally. Extra ocular muscles full and intact without any nystagmus or ptosis bilaterally.

Question 16

CN V:

Answer 16

Bilateral equal sensory to face intact to sharp and dull touch. Temporalis and masseter muscle strength and tone 5/5 bilaterally.

Question 17

CN VII:

Answer 17

Able to raise eyebrows, squeeze eyes shut, puff cheeks, smile and show teeth, purse lips and blow bilaterally. Facial muscles symmetrical and equal.

Question 18

CN VIII:

Answer 18

Whispered numbers heard bilaterally at one foot.

Question 19

CN IX, X:

Answer 19

Gag reflex deferred. . Uvula and soft palate midline without deviation. Phonation without hoarseness.

Question 20

CN XI:

Answer 20

Sternocleidomastoid and trapezius muscle strength 5/5 bilaterally.

Question 21

CN XII:

Answer 21

Tongue symmetric, midline without tremor or deviation on protrusion and moves equally in all directions.

Question 22

Sensory:

Answer 22

Sharp/dull distinction 2/2 bilaterally in upper extremities. Recognized 2/2 letters with graphesthesia and 2/2 objects with stereognosis to right hand. Vibration was felt in distal phalanx of right index finger and great toe.

Question 23

Cerebellar:

Answer 23

No dysdiadochokinesia on palm up/palm down bilaterally. Heel-shin and finger-nose-finger test performed without difficulty unilaterally. Finger-nose-finger test performed without difficulty bilaterally. Tandem walk performed without difficulty. No ataxic gate noted. Gait steady without limitations.

Question 24

Musculoskeletal examination:

Answer 24

No scoliosis observed with spinal flexion. Spine range of motion: flexion 45 degrees, extension 55 degrees, sidebending 40 degrees bilaterally, and rotation 70 degrees. Flexion and extension at shoulder, elbow, wrist, hip, knee, and ankle symmetric with muscle strength +5/5 bilaterally. Handgrip strength 5/5 bilaterally. Supraspinatus (bilaterally) and subscapular (right) strength noted as 5/5. Tinel’s and Phalen’s testing did not reveal tingling or pain over median nerve. Brudzinski test negative for nuchal rigidity or meningeal irritation.

Question 25

Lymphatic:

Answer 25

Negative lower extremity edema. Negative enlargement or tenderness of the occipital, posterior auricular, pre-auricular, tonsillar, mandibular, submental, anterior cervical, posterior cervical, supraclavicular, epitrochlear, popliteal, superior superficial inguinal, and inferior superficial inguinal lymph nodes.

Question 26

Upper/lower motor neuron/reflexes:

Answer 26

Biceps, triceps, brachioradialis, patellar, and Achilles reflex +2/4 on right side. No evidence of pronator drift. Babinski test deferred. Clonus test deferred.