Examiner : Kelley Goff, RN
Patient Initials : KJ Age: 50 Gender: Female
Reason for visit: recent severe heartburn
I. Health History 50 year old female in good health. No history of chronic illness. Smoker 1ppd x 24 years. Total hysterectomy at age 45. No other surgeries. Currently on no prescribed medications. No history of heart problems, lung problems, no urinary or bowel issues. No known kidney disease or liver disease. Family history of stroke (mother) and lung cancer (father). Both parents smokers. Both parents deceased.
II. Physical Examination
1. Inspection: Integument smooth, intact with no lesions; skin coloring is congruent with the rest of body; normal hair distribution; no sign of peristaltic movement; aortic impulse is visible
2. Auscultation: bowel sounds are audible in all four quadrants; no bruits are heard in left and right renal arteries or aorta.
3. Percussion Tympany is heard throughout with percussion; liver span is 6 cm at right midclavicular line. Splenic dullness heard at 10th intercostals space in left midaxillary line.
4. Palpation: no pain or tenderness reported with light and deep palpation; liver, spleen and both kidneys non palpable. Aortic impulse is slightly left of midline with an anterior pulsation; femoral pulses are equal and strong bilaterally; inguinal nodes are non-palpable. No guarding noted.
Summarize your findings using the SOAP format.
Subjective (Reason for seeking care, health history) 50 year old female with 2 week history of “heartburn” and “Upset stomach”. Good historian, states that “I don’t know much about my parent’s health because they didn’t go to the doctor”. No history of chronic illness. Smoker 1ppd x 24 years. Total hysterectomy at age 45. No other surgeries. History of superficial thrombophlebitis and pulmonary embolism in 2009. Coumadin therapy x1 year following. No further issues or complications. Currently on...
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