SOAP Case study – Please see attached f and further info from the Template 

 

 

 

CC Loose stools for 4-5 days

HPI: C.A is a 88 years old male who came to the clinic today accompanied by his wife for compliant of loose stools for 4 -5 days. Patient reports that diarrhea is followed by mild abdominal cramping which is relieved with defecation. He denies nausea or vomiting, he denies excessive flatus. Patient rated mild cramping at 2/10. He denies nausea or vomiting. Patient reports suing the bathroom about 4- 5times in a day which is out of his normal bowel routine of once every other day. Patient reports that his wife bought over the counter Imodium, 4mg which he took yesterday with mild relieve. Wife reports that this symptom keeps him awake especially at night and fears risk for fall considering his age, unsteady gait as well as other commodities. Patient denies fever or chills. Patient denies having any one sick at home and no change in diet or lifestyles and. No recent changes in diet or lifestyle.

 

 

 

 

Current Medications: Aleve 220mg 2 tabs every 6 hours PRN pain

Mirtazapine 30mg I tab po at bedtime.

Metformin HCL I tab with meals every AM

Vitamin D 2000units once daily

Omeprazole 20mg cap one tab 30minutes before meals

Atorvastatin Calcim 40mg one tab po daily

Tamsulon HCL 0.4mg I cap orally BID.

Amlodipine  Besy – benazepril HCL 5-40mg tab at night.

Allergies: NKDA , NKFA

PMHx: Hypertension, Hypercholesterolemia Right knee osteoarthritis, prostrate Cancer 1996, Hemorrhoids

Social HX Patient is a retired truck driver , he does not smoke, drink alcohol or illicit drugs.

FAMily HX –

Wife has Hypertension.

Son has elevated cholesterol, No history of colon cancer

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