History and Physical
Identifying Data:
Name: VP
Age: 5 years, 8 months
Race: Caucasian
Date & Time: 6/8/2020, 5:30 PM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self/Mother – Reliable
Mode of Transport: Personal vehicle
Chief Complaint:
Right elbow pain x 4 hours
History of Present Illness:
VP is a 5-year-old Caucasian female with no significant past medical history who presents with her mother complaining of right arm pain x 4 hours. Her mother reports that they were at their vacation home in Pennsylvania when VP and her older brother were playing and jumping on the bed. Her brother then picked her up and accidentally dropped her, causing her to fall on her right elbow from a height of about 3 feet. VP’s mother did not witness the fall, but immediately began the commute from Pennsylvania to the urgent care facility upon hearing her daughter’s cry. VP admits that the pain is constant and describes it as a sharp pain. Her mother gave her the appropriate dose of Children’s Motrin in the car approximately 30 minutes before entering the urgent care facility for mild relief. VP reported at the time of the injury that she felt some pain relief when holding her arm up, so her mother made her a temporary sling from a scarf at home. She admits that moving and touching her elbow makes the pain worse. The pain does not radiate. She is unable to rate the pain on a scale from 1 to 10 but admits that this is the worst pain she has ever felt. Her mother reports that VP’s right elbow is swollen with some bruising. VP reports that she is unable to move her right shoulder and elbow due to the pain but can wiggle her fingers. VP and her mother deny any breaks in the skin, loss of sensation, previous injury, previous radiographs, headache, changes in vision, other areas of pain, or any other symptoms. VP denies any head trauma, but her mother cannot confirm because she did not witness the fall. She has never been seen in this urgent care facility before.
Past Medical History:
Present illness:
VP’s mother denies any medical conditions
Past illness:
VP’s mother denies any past illnesses and injuries.
Hospitalizations:
VP’s mother denies any previous hospitalizations.
Immunizations:
VP’s mother reports that she is up to date with her vaccinations for her age group. She received an influenza vaccine in October 2019.
Past Surgical History:
VP’s mother denies any history of surgeries, injuries, and blood transfusions.
Medications:
VP does not take any medications on a daily basis.
Allergies:
VP’s mother denies any known allergies to medications, foods, or environmental factors.
Family History:
- Mother – Living, 36 years old
- Denies HTN, HLD, DM2, cardiovascular disease, history of malignancy, and any other medical conditions
- Father – Living, 38 years old
- Denies HTN, HLD, DM2, cardiovascular disease, history of malignancy, and any other medical conditions
- Maternal Grandmother – Living, 66 years old
- History of HTN; Denies history of HLD, DM2, history of malignancy, and any other medical conditions
- Maternal Grandfather – Living, 69 years old
- History of HTN and HLD; denies DM2, history of malignancy, and any other medical conditions
- VP’s mother is unable to provide specific information about VP’s paternal grandparents, but notes that both are living and healthy
Social History:
Travel:
VP was recently in Pennsylvania until earlier today. Her mother denies any other travel
Home:
VP lives at home with her parents and older brother.
Diet:
VP eats a balanced diet with little junk food. She drinks water, juice, and milk.
Sleep:
VP typically sleeps for at least 8 hours per night.
Exercise:
VP is appropriately active for her age
Safety:
VP uses all appropriate safety measures
Review Of Symptoms:
General:
Denies fever, chills, fatigue, weakness, and loss of appetite
Head:
Denies head trauma, headache, dizziness, and loss of consciousness
Eyes:
Denies use of corrective lenses, changes in vision, an photophobia
Neck:
Denies localized swelling/lumps, neck pain, stiffness, and decreased range of motion
Pulmonary:
Denies dyspnea, shortness of breath, cough, and wheezing
Cardiovascular:
Denies chest pain and known heart murmur
Musculoskeletal:
Admits to right elbow and forearm pain x 4 hours following fall. VP’s mother reports swelling and bruising in her right elbow and notes that she is unwilling to move her right arm. Denies any other areas of pain and joint deformity.
Nervous System:
Denies history of seizures, loss consciousness, and numbness or tingling in the affected arm.
Physical Exam:
Vital Signs:
Blood Pressure:
Pediatric BP cuff not available
Heart Rate:
106 bmp, regular
Respiration Rate:
18 bmp, non-labored
Temperature:
98.5 F, oral
O2 Sat:
99%, room air
Height:
43 inches
Weight:
39 lbs
General Appearance:
5-year-old female accompanied by her mother. Alert and oriented x 3. Patient appears scared and to be in some pain and has her arm in a homemade sling. Patient is in no acute distress.
Skin:
Skin warm and dry with good turgor. 2 cm x 1 cm hematoma on right elbow. No scars, rashes, or tattoos.
Nails:
Capillary refill <2 seconds throughout.
Head:
Normocephalic and atraumatic. Nontender to palpation throughout.
Eyes:
Symmetrical OU with no evidence of strabismus or ptosis. PERRLA. EOMI full without nystagmus.
Neck:
Trachea midline. Supple and nontender to palpation. FROM.
Chest:
Symmetrical without deformity or signs of trauma. Respiration unlabored and without use of accessory muscles. Non-tender to palpation.
Lungs:
Clear to auscultation bilaterally with no adventitious lung sounds.
Cardiovascular:
Regular rate and rhythm (RRR); S1 and S2 present without any murmurs, rubs, or gallops.
Abdomen:
BS present in all 4 quadrants. Soft and nontender without any masses or abnormal pulsations.
Peripheral Vascular:
Right arm –2 cm x 1 cm hematoma on the dorsal surface of the right elbow overlaying the medial condyle of the humerus. Edema extending from 3 cm above the elbow to 3 cm below the elbow. Warm to the touch with 2+ pulse palpated in the radial artery.
All other extremities within normal limits.
Musculoskeletal:
Edema extending from 3 cm above the elbow to 3 cm below the right elbow. Pain with palpation of the proximal third of the right forearm, elbow, and distal third of the upper arm. No pain with palpation of the shoulder, wrist, hand, and fingers. Nontender to palpation of the neck and back. Patient unwilling to display active range of motion in shoulder and elbow and resists passive range of motion due to pain. FROM in neck, wrist and digits. 5/5 muscle strength in digits bilaterally with weaker grip on the right side due to pain.
No edema or deformities in all other areas with FROM.
Neurological:
Sensation intact throughout.
Imaging:
Right forearm/elbow x-ray – Supracondylar fracture throughout the distal humerus with posterior displacement of the fracture fragments. Ulna and radius appear intact.
Right shoulder x-ray – There is no fracture, dislocation, or acute bone or joint abnormality. There is no acromioclavicular separation or fracture of the clavicle. Visualized portions of the right lung appear normal. Visualized ribs show no fracture.
Assessment:
5-year-old female with no significant past medical history presents with her mother complaining of right elbow pain x 4 hours. Imaging and clinical presentation are consistent with a supracondylar fracture of the right humerus with posterior displacement of the fracture fragments.
Differential Diagnosis:
- Fracture
- Right arm contusion
- Radial head subluxation
Plan:
- Supracondylar fracture of right humerus with posterior displacement of fracture fragments
- Patient referred to emergency room for further evaluation by orthopedist and fracture repair
- Arm stabilized in sling for travel
- Patient’s mother declines EMS transport and confirms that she will drive her daughter to the hospital
SOAP Note 6/1/2020
Name: JC
Age: 24 years
Race: Hispanic
Date: 6/1/2020, 9:30 AM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self – Reliable
Mode of Transport: Personal vehicle
S:
JC is a 24-year-old reliable Hispanic male with no significant past medical history complaining of a left knee laceration x 8 hours. He reports that was walking home from having drinks at a friend’s house last night when he tripped and cut himself on glass on the sidewalk. He reports that he washed off the wound with alcohol and peroxide when he got home, wrapped it in a bandage, and went to bed. When he woke up this morning (7 hours later) he noticed that he bled through the bandage and replaced it. He decided to seek medical attention when he noticed he was still actively bleeding through the newly applied bandage. He admits to current active bleeding and rates his pain as 5/10, but is worse with movement. He denies any decreased range of motion, loss of sensation, limitations to weight bearing, glass fragments in the wound, fever, chills, or any other symptoms. He denies any family history of bleeding disorders. He is unable to recall the date of his last tetanus booster.
PMHx:
Denies any significant past medical history
PSx:
Denies any past surgeries, injuries, or blood transfusions
Allergies:
NKDA
Medications:
Denies taking any medications on a daily basis
FHx:
Non-contributory
SHx:
JC drinks alcohol socially and was drinking at the time of the injury. He admits to occasionally smoking marijuana, but denies any use in the past month.
O:
Vitals:
Temperature: 98.9 F, oral
HR: 81 beats/minute, regular
BP: 122/76, right arm; sitting
RR 16 breaths/minute, nonlabored
SpO2: 98%, room air
Height: 5’10”
Weight: 162 lbs
Physical Exam:
General:
24-year-old male; alert and oriented x 3. He appears well groomed and appropriately dressed and has a bandage on his left knee. In no acute distress.
Skin:
2.0 cm vertical laceration on the lateral side of the left knee; actively bleeding. Skin is warm and moist throughout without discoloration.
Respiratory:
Lungs clear to auscultation without adventitious lung sounds or accessory muscle use.
CV:
RRR without murmurs, rubs, or gallops
Abdomen:
BS+ in all 4 quadrants; soft, nontender to palpation, nondistended
Extremities:
Warm and well perfused; 2+ popliteal and dorsalis pedis pulses bilaterally
Musculoskeletal:
No muscle or joint abnormalities observed. FROM in lower extremities bilaterally. 5/5 muscle strength in lower extremities bilaterally.
Neurological:
Sensation intact bilaterally in the lower extremities.
Imaging:
Left knee x-ray – No acute fracture or foreign bodies visualized.
A:
JC is a 24-year-old reliable Hispanic male with no significant past medical history complaining of a left knee laceration x 8 hours. Physical exam and imaging are consistent with a 2.0 cm left knee laceration without foreign bodies in the wound.
P:
- Left knee laceration without foreign body
- Wound irrigated with normal saline
- 10 mL of 1% lidocaine administered to the affected area for local anesthesia
- (4) 3-0 polypropylene simple interrupted sutures applied for laceration repair
- Bacitracin applied over the sutures and bandage applied
- Patient instructed to remove the wound dressing in 24 hours and gently clean the wound with soap and water
- Avoid strenuous activity until the wound is properly healed
- Return to the clinic in 7-10 days for wound evaluation and suture removal
- Encounter for Td immunization
- 5 mL single dose Td booster administered to left deltoid
- Lot: A122A
- Expiration: 11/29/2021
- Patient informed that he may experience soreness and stiffness in his left arm for 1-2 days following vaccination and may experience a low-grade fever.
- 5 mL single dose Td booster administered to left deltoid
SOAP Note 6/9/2020
Name: JC
Age: 24 years
Race: Hispanic
Date: 6/9/2020, 12:30 PM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self – Reliable
Mode of Transport: Personal vehicle
S:
JC is a 24-year-old reliable Hispanic male with no significant past medical presenting for wound evaluation and suture removal. He initially presented to the clinic on 6/1/2020 complaining of a left knee laceration after falling on glass the previous night. A left knee x-ray revealed no acute fracture or foreign bodies in the wound. (4) 3-0 polypropylene simple interrupted sutures were applied to repair the 2.0 cm vertical laceration on the lateral side of the left knee. Neurovascular status was intact at the time of evaluation and he had FROM in his lower extremities bilaterally. He also received a Td booster in the left deltoid at that visit. Today he reports that he only feels a mild sensation of tightness at the suture site with full flexion of the left knee. He denies any fever, pain, erythema, or swelling surrounding the suture site, decreased ROM, numbness or tingling, or any other symptoms. He reports that he was compliant with the instructions for wound care and follow-up he was given at the initial visit.
PMHx:
Denies any significant past medical history
PSx:
Denies any past surgeries, injuries, or blood transfusions
Allergies:
NKDA
Medications:
Denies taking any medications on a daily basis
FHx:
Non-contributory
SHx:
JC drinks alcohol socially and was drinking at the time of the injury. He admits to occasionally smoking marijuana, but denies any use in the past month.
O:
Vitals:
Temperature: 98.4 F, oral
HR: 86 beats/minute, regular
BP: 118/78, right arm; sitting
RR 16 breaths/minute, nonlabored
SpO2: 98%, room air
Height: 5’10”
Weight: 162 lbs
Physical Exam:
General:
24-year-old male; alert and oriented x 3. He appears well groomed and appropriately dressed. In no acute distress.
Skin:
2.0 cm vertical laceration on the lateral side of the left knee repaired with (4) 3-0 polypropylene simple interrupted sutures. No swelling, erythema, or signs of infection at the site of the laceration. The laceration appears to have healed properly and is ready for suture removal. Skin is warm and moist throughout without discoloration.
Respiratory:
Lungs clear to auscultation without adventitious lung sounds or accessory muscle use.
CV:
RRR without murmurs, rubs, or gallops
Extremities:
Warm and well perfused; 2+ popliteal and dorsalis pedis pulses bilaterally
Musculoskeletal:
No muscle or joint abnormalities observed. FROM in lower extremities bilaterally before and after suture removal. 5/5 muscle strength in lower extremities bilaterally.
Neurological:
Sensation intact bilaterally in the lower extremities.
A:
JC is a 24-year-old reliable Hispanic male with no significant past medical presenting for wound evaluation and suture removal following the application of (4) 3-0 polypropylene simple interrupted sutures to repair a left knee laceration on 6/1/2020.
P:
- Left knee laceration – encounter for suture removal
- Suture site cleaned with alcohol.
- (4) sutures removed using scalpel and forceps
- JC instructed to return to the clinic if he develops any fever, pain, swelling, or erythema around the suture site, or any other symptoms.
SOAP Note 6/6/2020
Name: AG
Age: 44 years
Race: Hispanic
Date: 6/6/2020, 4:30 PM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self – Reliable
Mode of Transport: Personal vehicle
S:
AG is a 44-year-old reliable Hispanic male with no significant past medical presenting complaining of right eye pain x 2 hours. He reports that he was cutting metal at work without eye protection when he felt a piece go into his right eye. He has since been experiencing 7/10 pain in his right eye, tearing, and difficulty opening his eye. When he is able to open his eye, he denies any changes in his vision and endorses mild photophobia. He denies any crusting, eyelid swelling, fever, chills, or any other symptoms. He does not wear corrective lenses. He reports that his tetanus booster is up to date.
PMHx:
Denies any significant past medical history
PSx:
Denies any past surgeries, injuries, or blood transfusions
Allergies:
NKDA
Medications:
Denies taking any medications on a daily basis
FHx:
Non-contributory
SHx:
AG has 2-3 beers occasionally on the weekends. He denies any tobacco or illicit drug use.
O:
Vitals:
Temperature: 98.7 F, oral
HR: 91 beats/minute, regular
BP: 142/91, left arm; sitting
RR 16 breaths/minute, nonlabored
SpO2: 98%, room air
Physical Exam:
General:
44-year-old male, alert and oriented x 3. He appears well-groomed and appropriately dressed. He is sitting on the exam table with his eyes closed with visible tearing in the right eye, but in no acute distress.
Eyes:
Patient initially sitting with eyes closed. No periorbital edema or erythema noted. No tenderness to palpation in the periorbital region. Mild tenderness to palpation overlaying the right upper eyelid. Significant tearing noted from the right eye. Right sclera and conjunctiva erythematous. Left eye unremarkable. No discharge visualized bilaterally. Right eyelid inversion reveals small, gray metal piece of debris beneath the
upper eye lid that is removed with a cotton-tipped applicator. AG notes some relief after removal. PERRLA, EOMI bilaterally. Visual acuity 20/20 OD, OS, OU. Fluorescein stain and blue light exam of right eye negative for corneal abrasion.
Respiratory:
Lungs clear to auscultation without adventitious lung sounds or accessory muscle use.
CV:
RRR without murmurs, rubs, or gallops
A:
AG is a 44-year-old reliable Hispanic male with no significant past medical history presenting with a complaint of right eye pain x 2 hours. Examination is consistent with right eye pain due to foreign body.
P:
- Right eye pain due to foreign body
- Moxifloxacin eye drops prescribed prophylactically for infection
- 1 drop in the right eye TID x 5 days
- Instructed to return to the clinic or follow up with an ophthalmologist if symptoms persist or worsen
- Counselled on the importance of protective eye equipment to prevent future injuries
- Moxifloxacin eye drops prescribed prophylactically for infection
SOAP Note 6/20/2020
Name: GA
Age: 15 years
Race: Caucasian
Date: 6/20/2020, 7:15 PM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self – Reliable
Mode of Transport: Personal vehicle
S:
GA is a reliable 15-year-old female-to-male transgender male with a significant past medical history of Bipolar 1 Disorder accompanied by his father presenting to the clinic complaining of left-sided chest pain x 2 days. He reports that the pain started suddenly 2 days ago and is constant. He describes it as a soreness He admits that he experiences 7/10 pain with movement and taking deep breaths. He reports that the pain became severe enough last night that he presented to Forest Hills Hospital. He had an EKG done that revealed a normal result and was sent home without further evaluation. He denies any fever, chills, body aches, coughing, sore throat, SOB, pain radiation, trauma, burning sensation in his throat, nausea, vomiting, sour taste in his mouth, or any other symptoms. He did not take any OTC pain medication and notes that nothing alleviates the pain. He admits to wearing a store-bought binder most days and only takes it off to sleep. He presented to the clinic today because the pain has not improved. He is not undergoing any hormone therapy.
PMHx:
Bipolar 1 Disorder x 2 years
PSx:
Denies any past surgeries, injuries, or blood transfusions
Allergies:
NKDA
Medications:
- Lithium 450 mg PO BID
- Last dose this morning
- Aripiprazole 10 mg QD
- Last dose this morning
FHx:
Non-contributory
SHx:
GA denies any alcohol, tobacco, or illicit drug use.
O:
Vitals:
Temperature: 98.3 F, oral
HR: 87 beats/minute, regular
BP: 119/72, right arm; sitting
RR 18 breaths/minute, nonlabored
SpO2: 98%, room air
Physical Exam:
General:
15-year-old male alert and oriented x 3. He is well-groomed and dressed appropriate. In no acute distress
Skin:
Non-diaphoretic. Warm and moist. No evidence of cyanosis or other discoloration. Capillary refill <2 seconds throughout. No clubbing.
Lungs:
Clear to auscultation without any adventitious lung sounds or accessory muscle use bilaterally. Patient reports pain on deep breathing.
Heart:
RRR. S1 and S2 present without any murmurs, rubs, or gallops. PMI in appropriate position and no heaves noted.
Musculoskeletal:
No bruising or abnormality noted. Tenderness to palpation over the left lower ribs from the sternum to the anterior axillary line. FROM with pain. No tenderness to palpation over the right ribs, neck and back. All other areas are within normal limits.
Imaging:
Chest X-Ray – Normal
EKG:
Normal sinus rhythm; normal EKG
A:
15-year old transgender male with a significant past medical history of Bipolar 1 Disorder presents accompanied by his father complaining of left chest pain x 2 days. Physical exam and in-clinic testing consistent with costochondritis secondary to wearing a tight binder on a daily basis.
P:
- Costochondritis
- Patient advised to take over the counter NSAIDs as needed for pain
- Advised not to wear binder until symptoms resolve
- Informed that symptoms could last from anywhere between a few days to a few months
- Return to the clinic or go to the ED if symptoms persist or worsen or if patient develops fever or SOB
- Patient had no questions at this time
- Bipolar 1 Disorder
- Continue medications as directed
- Follow up with prescribing provider with questions or concerns
SOAP Note 6/22/2020
Name: BT
Age: 21 years
Race: Caucasian
Date: 6/22/2020, 6:45 PM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self – Reliable
Mode of Transport: Personal vehicle
S:
BT is a 21-year-old female with no significant past medical history who presents accompanied by her mother complaining of upper abdominal pain x 1 day. She was seen in the clinic yesterday morning complaining of hives from an allergic reaction and was given a Dexamethasone injection and was prescribed oral Prednisone and Famotidine. She took 2 doses of the prescribed medications and later developed her upper abdominal pain. She describes the pain as severe cramping that comes and goes but has been more or less constant for the last 2 hours. She also admits to nausea, decreased appetite, and multiple episodes of diarrhea today. She has been able to tolerate small sips of water. She reports that the pain is worse when she lays down on her back. She denies fever, chills, vomiting, blood in her stool, introduction of any new foods or takeout, sick contacts, chance of pregnancy, vaginal bleeding or abnormal discharge, irritative voiding symptoms, pain radiation, or any other symptoms. She reports that her last menstrual period was 1 week ago. She did not take any OTC treatments for her pain or diarrhea.
PMHx:
Denies any significant past medical history
PSx:
Denies any past surgeries, injuries, or blood transfusions
Allergies:
NKDA
Medications:
Prednisone 20 mg QD x 10 days
Famotidine 20 mg BID x 14 days
FHx:
Non-contributory
SHx:
BT denies any alcohol, tobacco, or illicit drug use
O:
Vitals:
Temperature: 98.6 F, oral
HR: 109 beats/minute, regular
BP: 90/54, right arm; sitting
Yesterday’s BP: 115/78, right arm; sitting
RR 18 breaths/minute, nonlabored
SpO2: 98%, room air
Physical Exam:
General:
21-year-old female alert and oriented x 3. Well-groomed and dressed appropriately. Sitting on exam table hunched over while clutching her abdomen. Appears to be crying in pain. In mild distress.
Respiratory:
Lungs clear to auscultation without adventitious lung sounds or accessory muscle use.
CV:
RRR without murmurs, rubs, or gallops
Abdomen:
Flat and nondistended without abnormal pulsations or skin abnormalities. BS present in all 4 quadrants. Tenderness to light and deep palpation with some guarding in the RUQ and LUQ, more severe in LUQ. Murphy sign negative. Rovsing, Psoas, and Obturator signs and McBurney’s point tenderness negative. No CVAT bilaterally.
A:
BT is a 21-year-old female with no significant past medical history who was treated 1 day ago for an allergic reaction with a Dexamethasone injection and oral Prednisone and Famotidine who returned to the clinic complaining of severe upper abdominal pain x 1 day. Physical exam and history are suggestive of possible acute pancreatitis induced by corticosteroid administration.
P:
- LUQ/RUQ pain
- Patient referred to the ED for further evaluation with US and blood analyses to rule out acute pancreatitis or gallbladder pathology due to severe pain.
- Patient understood and was given the opportunity for questions, but had none at this time
- Patient advised to discontinue prescribed medications until work-up completed and further instructions are given by ED providers
- Acute Pancreatitis
- NPO
- Abdominal US – to rule out gallbladder pathology and assess for fluid around the pancreas
- Serum analyses
- CBC
- CMP
- Amylase
- Lipase
- IV fluids
SOAP Note 6/9/2020
Name: AS
Age: 71 years
Race: Caucasian
Date: 6/22/2020, 10:30 AM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self – Reliable
Mode of Transport: Personal vehicle
S:
AS is a 71-year-old male with a significant past medical history of HTN and HLD controlled with medication who presents complaining of bilaterally decreased hearing x 2 weeks. He reports that he often gets cerumen impactions and gets treated by his ENT at the VA but has been unable to get an appointment due to the pandemic. He admits to wearing bilateral hearing aids and has found that his hearing has been muffled for the last two weeks. He has been using Debrox ear drops for 1 week with no relief. He denies any ear pain, discharge from his ears, foreign bodies, sore throat, fever, chills, or any other symptoms. He admits to regularly following up with his audiologist every 6 months with his last appointment about 2 months ago.
PMHx:
HTN x 15 years
HLD x 15 years
PSx:
Appendectomy in childhood
Allergies:
NKDA
Medications:
- Enalapril 20 mg QD
- Last dose this morning
- Atorvastatin 10 mg QD
- Last dose this morning
- Aspirin 81 mg QD
- Last dose this morning
FHx:
Non-contributory
SHx:
AS denies any alcohol, tobacco, or illicit drug use
O:
Vitals:
Temperature: 98.6 F, oral
HR: 82 beats/minute, regular
BP: 136/88, right arm; sitting
RR 18 breaths/minute, nonlabored
SpO2: 96%, room air
Physical Exam:
General:
71-year-old male alert and oriented x 3. Well-groomed and dressed appropriately. In no acute distress.
Ears:
Patient wearing hearing aids bilaterally and having some difficulty hearing when spoking to and following commands as a result; more so when hearing aids removed. Unable to discern whispered voice bilaterally with and without hearing aids. Ears even with no obvious abnormalities bilaterally. No tenderness to palpation of the tragus or with manipulation of the pinna bilaterally. External ear canals non-erythematous and without foreign body. Brown cerumen occluding external ear canals bilaterally such that TMs are not visualized.
After irrigation: External ear canals non-erythematous and without foreign body bilaterally. TMs pearly gray with cone of light in appropriate position bilaterally. No evidence of effusion. Patient reports improved hearing with auditory acuity intact to whispered voice.
Pharynx:
Posterior pharynx non-erythematous and without edema. Grade 1 tonsils without exudates. Uvula midline
Neck:
No tenderness to palpation and no palpable cervical lymphadenopathy. FROM without pain
Respiratory:
Lungs clear to auscultation without adventitious lung sounds or accessory muscle use
CV:
RRR without murmurs, rubs, or gallops
A:
AS is a 71-year-old male with a significant past medical history of HTN and HLD controlled with medication who presents complaining of bilaterally decreased hearing x 2 weeks. Physical exam is consistent with bilateral cerumen impaction.
P:
- Bilateral cerumen impaction
- 1:1 ratio of hydrogen peroxide and warm water used to irrigate ear canals bilaterally
- Patient tolerated procedure well
- Instructed to return to the clinic or follow up with his ENT provider if symptoms return or if he develops any ear pain, fever, or any other symptoms
- Cautioned against using Q-tips in ear canals to prevent future impactions and injury to ears
- 1:1 ratio of hydrogen peroxide and warm water used to irrigate ear canals bilaterally
SOAP Note 6/15/2020
Name: GD
Age: 27 years
Race: Hispanic
Date: 6/15/2020, 9:50 AM
Location: Centers Urgent Care – Queens, NY
Source of Referral: None
Source of Information: Self – Reliable
Mode of Transport: Personal vehicle
S:
GD is a 27-year-old G1P1001 Hispanic female with no significant past medical history who presents complaining of dysuria x 3 days. She reports that she has had a burning sensation with urination and urinary frequency and urgency for the past 3 days. She also reports some lower abdominal pressure for 1 day. She has had urinary tract infections in the past and admits that her symptoms feel like previous experiences of this. She took over the counter AZO for little relief. She reports that her last menstrual period was 2 weeks ago, and she has had unprotected sex with her husband since then. She denies any fever, chills, back pain, flank pain, hematuria, vaginal bleeding, vaginal discharge, nausea, vomiting, diarrhea, constipation, or any other symptoms. She reports that she has gotten yeast infections following antibiotic therapy on multiple occasions.
PMHx:
Denies any significant past medical history
PSx:
Denies any past surgeries, injuries, or blood transfusions
Allergies:
NKDA
Medications:
AZO x 2 days
2 tablets TID
FHx:
Non-contributory
SHx:
GD admits to socially drinking alcohol and denies any tobacco and illicit drug use
O:
Vitals:
Temperature: 99.1 F, oral
HR: 89 beats/minute, regular
BP: 121/86, right arm; sitting
RR 18 breaths/minute, nonlabored
SpO2: 99%, room air
Physical Exam:
General:
27-year-old female alert and oriented x 3. Well-groomed and dressed appropriately. In no acute distress
Respiratory:
Lungs clear to auscultation without adventitious lung sounds or accessory muscle use
CV:
RRR without murmurs, rubs, or gallops
Abdomen:
Flat and nondistended. BS present in all 4 quadrants. Nontender to palpation throughout but reports some pressure with palpation over the bladder. No CVAT bilaterally
Labs:
Urinalysis:
Color: Orange and clear
Leukocytes +
Nitrites +
Blood –
Ketones –
Bilirubin –
pH 6.5
Specific gravity 1.020
Urine HCG:
Negative
A:
GD is a 27-year-old G1P1001 Hispanic female with no significant past medical history who presents complaining of dysuria x 3 days. Urinalysis and history consistent with a simple urinary tract infection.
P:
- UTI
- Nitrofurantoin 100 mg BID x 10 days
- Urine culture with sensitivities sent to lab
- Educated on proper UTI prevention (wiping front to back, urinating after sex, hydrating well, not holding urine, etc.)
- Return to the clinic or follow up with PCP if symptoms do not resolve or worsen
- Vulvovaginal candidiasis prophylaxis
- Diflucan 150 mg PO QD x 1 day
- Instructed to take only if she experiences vaginal itching/irritation or white discharge consistent with previous experiences following completion of antibiotic
- Diflucan 150 mg PO QD x 1 day
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