Posted: March 16th, 2022

NSG 6020 iHuman Soap Note – 50-Year Old Patient with Left Groin Pain

Inguinal Hernia
NSG 6020 iHuman Soap Note – 50-Year Old Patient with Left Groin Pain: Inguinal Hernia
NSG 6020 iHuman Soap Note – 50-Year Old Patient

SOAP NOTE

Name: Mr. B. Date: May 27, 2018 Time: 2:44PM
Age: 50 years old Sex: Male
SUBJECTIVE
CC:
“I’ve got this horrible pain in my left groin, doc. Please do something. It’s killing me.”

HPI:
Seen and examined Mr. B, a 50-year old Caucasian Male presented in the clinic for left groin pain 10/10.

Has chronic Hypertension that is controlled with Lisinopril taken daily.

Onset – Six hour ago.

Location – left groin pain radiating to scrotal area

Duration – Constant and getting worse

Characteristic – Sharp, stabbing pain that feels like “tearing” inside

Aggravating factors: Standing and bending makes it worse

Relieving factors: No other factors found to helpful at this time.

Treatment – Seek medical attention

Medications:
Lisinopril 20mg daily for Hypertension

PMH
Allergies: No known Allergies

Medication Intolerances: None

Chronic Illnesses/Major traumas: Hypertension

Hospitalizations/Surgeries

Extracorporeal Shockwave Lithotripsy – years ago

Family History
Mother – Hypothyroidism, Breast Cancer

Father – Hypertension, CAD, prostate cancer

Indicates Patient

Living Male

Living Female

Nose/Mouth/Throat

Denies having any lesions, masses and tenderness. Also denies difficulty of hearing, vertigo and throat pain.

Musculoskeletal

Denies weakness, stiffness and joint pain

Breast

Denies rashes, bruising, sores, lumps, dryness and color changes.

Neurological

Denies numbness and tingling, denies having vision or hearing problems, tremors, and gait instability.

Heme/Lymph/Endo

Denies easy bruising and bleeding, Denies heat or cold intolerance, and denies having swollen lymph nodes.

Psychiatric

Denies anxiety, depression, difficulty sleeping and suicidal ideation.

OBJECTIVE

Weight 180 lbs BMI 24.4 Temp 99.0 BP 170/94
Height 6’0” Pulse 130 – regular Resp 18
General Appearance
Seen and examined Mr. B, 50-year old Caucasian male complains left groin constant pain. Appears to be mobile and pleasant but looks frustrated from constant pain. Alert and oriented x 4, answers all questions appropriately and very cooperative.

Skin
Intact, diaphoretic with no bruising, lesions, rashes or discoloration noted. No cyanosis or clubbing noted. No visible scars observed. Skin color is appropriate for ethnicity.

HEENT
· Normocephalic

· Conjunctiva pink, sclerae white, no jaundice, free from drainage, PERRLA. 20/20 vision

· Ears non-tender, no swelling and free from drainage

· Nose: nasal mucosa moist without drainage, septum midline, free from swelling and lesions

· Throat: free from lesions and not enlarged

· Neck: Trachea is midline, non-palpable thyroid and lymph nodes, neck supple with no masses or tenderness.

Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory
Symmetrical chest expansion. Respirations even and unlabored, breath sounds clear upon ausculatation bilaterally. No wheeing, rhonchi, or stridor noted. No increased tactile fremitus.

Gastrointestinal
Abdomen flat, soft, non-distended, Bowel sounds present on all quadrants. Abdomen tympanic with percussion, Non-tender when palpated and no hepatosplenomegaly. Mildly swollen, indurated left groin causing tension to overlying skin.

Breast
-Normal, non-tender. No masses, lumps, deformities, ulcerations or discharge.

Genitourinary
-left groin visibly swollen and indurated upon palpation. Right groin normal.

-tenderness present on the left inguinal canal ; right inguinal canal normal

-left scrotal area swollen

– testicles are normal in size and non-tender upon palpation

-Normal Penile shaft, without lesions or discharge

-No flank tenderness to percussion

Assessment: For Inguinal Hernia

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NSG 6020 Week 5 SOAP Note Assignment
SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W5_A2_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 6 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W6_A4_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 6 Physical Exam Video and Write Up Assignment

Complete Health History and Physical Assessment Write-Up Presentation

This assignment consists of complete head to toe physical while being videoed. You will also need to complete a written assignment of your findings. Review the Expanded rubric to note how you will be graded on this assignment.

Week 7 SOAP Note Assignment

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W7_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 8 SOAP Note Assignment

SOAP Note

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W8_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 9 SOAP Note Assignment

SOAP NOTE

Each week you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. Beginning in Week 5, you will need to include one complete SOAP note each week through Week 9 for a total of 5 complete SOAP notes for this course using this SOAP note template. The SOAP note should be related to the content covered in this week, and the completed SOAP note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE where you entered this specific patient’s case entry.

Submission Details:

By the due date assigned enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6020_W9_A3_LastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

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