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Patient's Family, Medical, Surgical and Immunization History (Case Study Sample)


The case study completed involved gathering the client's history of presenting complain, family history, medical and surgical history and immunization history among others. The data collected is used generate various differential diagnosis and a definitive diagnosis which is verified using laboratory assessment and radiology. The paper is in APA format and has four sources


SOAP Note Assignment
Advanced Practice in Primary Care I
Name: C. S


Time : 1000hrs

DOB: 05/22/1987

Sex: Female

Race: Caucasian

AGE: 33 years

Subjective: The patient is here due to a constant dull flank pain

Chief Complain (CC):   “I have been having continuous pain deep into my right side of the abdomen and back for two days now. Sometimes I vomit and I feel hot all the time”

History of Presenting Illness (HPI):
C.S is a 33 years old female who presented to the clinic with complains of continuous pain in her right side of the abdomen, episodes of vomiting and fever. The following is the history of her illness;
Onset: the pain started two days ago and could not be alleviated completely by Tylenol. She has had at least three episodes of vomiting for each of the two days.
Location: the pain is located on her right of the abdomen with higher intensity at the area between the lower ribs and the iliac crest.
Duration: the dull pain has lasted for two days now
Characteristics: the pain is constant, aching type and comes from deeper parts of the right side of the abdomen.
Alleviating/aggravating factors: To some extent intake of Tylenol has reduced the intensity of the pain for some time. Palpation, pressure or hitting of the right side are some of the factors that increases the pain.
Radiation: the patient has no experience of pain in another part of the body
Treatment: for the two days the patient has taken Tylenol for five times. She is on Tri-Cyclen 28 one tablet daily. That she started before the pain started.
Severity: the level of pain when it is worse on a scale of 1 to 10, 1 being mild pain and 10 being very severe pain is 8.
Pertinent positives/ negatives: The patient has had three episodes of cystitis for three times. The recent one was two months ago. She is sexually active and she denies any lower urinary tract symptom such as dysuria.

Medications: Tylenol for pain on PRN basis; Tri-Cyclen 28 ones a day
Allergies: none

Past Medical Illnesses (PMI): The patient reports three episodes if urinary tract infection specifically cystitis in 2 years, 8 months and 2 months ago respectively
Illnesses/Injuries: none
Childhood: no childhood illnesses
Adult: has had urinary tract infection for three times.
Hospitalizations/Surgeries: no personal history of hospitalizations or surgeries
Obstetrics: G3 P3. Uses Tri-Cyclen 28 for family planning
Influenza- Pneumovac-N/A Tetanus- HPV-Gardasil-2016 Hep B-
Health Maintenance: The patient went for antenatal clinics during her pregnancies for at least four time in each pregnancy. She has been using family planning. The patient has been visiting the clinic at least two time every year. Recently, she has visited the clinic for three times in one year only two months apart due to cystitis. The patient takes about two glasses of water every day and prefers other fluids over water. She gets enough sleep of about 7 hours a day. She visited a dentist 6 months ago.
Last mammogram- no history
Last pap smear- 08/2019 negative result for intraepithelial cells, lesion or malignancy
Last colonoscopy- N/A
Last prostate exam- N/A

Family History (FH):
Stroke- none
Lung disease- none
HTN- none
Heart disease- none
Cancer- none

Social History (SH):
Patient lives with her husband, her mother and their three children in a 5 bedroom house
She works in a back as credit officer.
The patient takes a glass of wine every day after evening meals. She takes a bottle of bear every week.
Does not smoke and does not use recreational drugs
She is sexually active with one men and uses birth control

Review of Systems (ROS)

General: Denies any change in weight, weakness, fever, chills, night sweats.

Breast/chest: Denies any bumps, lumps, pain, skin changes, and no nipple discharge. Self-breast exam monthly

Skin: Denies any rashes, pruritus, no nail or hair changes, no sores, lumps or moles.

Gastrointestinal: Denies, indigestion, dysphagia, no change in bowel movement, diarrhea, constipation, blood in her stool, abdominal pain or jaundice.
Complains of 6 episodes of vomiting in the last two days
Reports nausea and reduced appetite

Head/Eyes: Denies headaches, does not wears contact lenses, and denies any blurred vision, tearing, itching, acute visual changes, pain, redness, dryness or drainage. Last eye exam Dec/2019.

Genitourinary/Gynecological: Denies irregular periods, last menstrual period: 05/28/2020. Denies urgency, frequency, dysuria, hesitancy, nocturia, incontinence, or infection, vaginal discharge, vaginal pruritus, lack of sex drive.
Reports of right sided flank pain on palpation, and reduced urine output that is blood tinged (hematuria).

Ears: Denies decreased in hearing, tinnitus, vertigo, earache, vertigo or discharge. No hearing aids.

Hematologic/lymphatic/immunologic: Denies anemia, easy bruising or bleeding, no past blood transfusion.

Nose/Mouth/Throat: Denies bleeding gums or sores, rhinorrhea, stuffiness, sneezing, itching, allergy, epistaxis, hoarseness, sore throat.
Last dental visit 6 months ago.
Neck: Denies lumps, goiter, swollen lymph nodes.

Musculoskeletal: Denies joint pain, swelling or redness, muscle weakness, joint stiffness, instability or decreased ROM.

Cardiovascular: Denies chest pain, dyspnea, palpitations, no dyspnea of exertion, orthopnea or edema.

Neurological: Reports occasionally headaches, denies fainting, weakness, seizure, motor or sensory loss, memory, tingling or tremors. No inability to speak, paralysis, numbness or disturbances in coordination.

Respiratory: Denies any cough, sputum, wheezing, hemoptysis, shortness of breath or asthma.

Psychiatric: Denies depression, sleeplessness, anxiety, mania, psychosis, suicidal ideation.

Endo: Denies thirst, frequent urination (day time), cold Intolerance.
Reports episodes of feeling hotness of the body


Wt: 130lb (59.0kg)

Temp: 101.0 F(oral) (38.2O C)

Pulse: 114 BPM

BMI: 21.0

Ht: 5’6” (168.0 cm)

BP: 120/60 mmHg (supine/sitting)
108/56 mmHg (upon standing)

Resp:14 BPM

SPO2: 98% on room air

Physical Exam

General Appearance: C.S. is a pleasant female patient, she is alert and oriented to person, time, place and situation, well-groomed and cooperative. Behavior is appropriate. No acute distress.

Skin: Warm and dry, no skin lesion, no rashes, no petechias, no ecchymosis, no scars, no tattoos.

Head is normocephalic without signs of trauma. Hair is clean with normal texture. No hair infestation. No nevus, scar, or lumps on the scalp.
Eyes. Eyelids close completely, no lesions or lumps. No lacrimal duct drainage noted. Sclera is white and palpebral conjunctiva is pink and moist. Pupils are equally round, reactive to light and accommodation bilaterally. Extra ocular muscles Movement intact. No muscle imbalance. Fundi: Optic disc sharp, no exudates or hemorrhages. No narrowing vessels.
Ears: Pinna of ears line up with the outer canthus of the eyes bilaterally. No lesions, no nodules. EAC without erythema, discharge, foreign body or cerumen obstruction bilaterally. Tympanic membranes with good cone reflex, no bulging or redness.
Nose: No trauma, nasal bridge with no bumps. No frontal or maxillary sinus tenderness. The septum is in midline. Nasal mucosa is pink and moist, no ulcers, no polyps, medium turbinate’s with no swelling bilaterally.
Throat/mouth: Lips are symmetric, pink and moist with no lesions. Tongue protrudes at midline, pink and moist, no lesions or swelling. No halitosis. Buccal mucosa pink and moist, no lesions or discolorations. All teeth are present, no dental work or caries noted. Hard palate is fused, soft palate is pink and moist. Uvula is at midline, no enlargement of the tonsils. Pharynx without exudates.
Neck: supple. Trachea midline. Thyroid lobes not enlarged, no lumps or JVD noted. No adenopathy (preauricular, post auricular, posterior and anterior cervical chain, submandibular, submental or supraclavicular)
Carotid pulses 2+, no carotid bruit.

Cardiovascular: point of maximal impulse (PMI) not visualized. S1, S2 auscultated. Regular Rate And Rhythm (RRR). No murmurs, no extra sounds, no thrill.

Respiratory: Thorax is symmetric with good bilateral expansion, AP diameter 2:1, no muscle retractions, lungs resonant, tactile and v...

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