SOAP NOTE

ID: 33 y/o M w/ PMH of substance abuse p/w perforated duodenal ulcer s/p
Grahams patch on 4/10/15.
S: Pt doing well and resting comfortably. Pt states his pain is 8/10 around
abdominal midline incision. Pt denies any fevers, nausea, vomiting over
night.
O: Vitals- Tm 99.5 @ 1400 4/9
RR 16-18 100% on RA

Tc 98.7

BP 112/82- 143/88 P 85-102

Gen: Pt in no acute distress. Resting comfortably.

HEENT: EOMI, PERRLA, no masses, no thyromegaly
CV: Tachycardic, regular rhythm, normal S1, S2, no murmurs, rubs, or
gallops
Pulm: CTAB, no wheezes, rhonchi or crackles
GI: Non-tender, Non-distended, tender to palpation along midline incision
Neuro: A & O x4, CN II-XII grossly intact, no focal deficits
MSK/Ext: Moves all extremities spontaneously, 5/5 strength, no edema, no
cyanosis
A/P:
33 y/o M w/ perforated duodenal ulcer s/p Grahams patch on 4/10/15.
1) Perforated duodenal ulcer s/p Grahams patch
a. Wound healing well, wrapped in krilex and gauze, no active
bleeding, no pus, no erythema, no signs of infection. Continue
wound care.
b. JP drains- 5ml of serosangenous fluid. Continue to monitor for
abnormal fluid. Monitor fluid collection.
2) Tachycardia likely secondary to pain vs. infection
a. Pain well controlled on morphine and Norco10. Continue pain
management.
b. Pt afebrile. Monitor patient for fevers/signs of infection.
Continue Abx therapy.
3) H/o substance abuse
a. Social services to discuss rehabilitation.
b. Encourage patient to quit substance abuse.