Using the provided sample case study complete the chart. The case study is missing information so the rest must be made up to fit the patient. Case #3. Vivian.
History of Present Illness (HPI): Vivian is an 88-year-old Caucasian female brought into the office by her
caregiver. Complains of dark, cloudy, foul-smelling urine, with new confusion and night-time
hallucinations. The caregiver reports a history of disturbed night sleep, with hallucinations of spiders
crawling in bed, followed by agitation, lethargy, and poor oral intake the next morning. Other symptoms
include increased urinary frequency, dysuria, mild fever, and lower abdominal pain. The caregiver also
reports that Vivian had been treated for suspected UTI twice in the last 12 months.
Prior medical history: HTN, CKD stage 2, diverticular disease, vesicovaginal fistula (newly diagnosed),
previous indwelling urinary catheter, osteoporosis, left femur fracture s/p fall.
Prior surgical history: Left Total Hip Replacement (2012).
Current medications: Olmesartan 20mg daily, Alendronate 70mg weekly, Vitamin D3 5,000 IU daily.
Allergies: None
Social history: Never smoked or drank alcohol. Lives alone with 24-hour caregiver after husband died 3
years ago and she had a fall that resulted in femur fracture.
Family history: Mother deceased (age 74)- breast cancer. Father deceased (age 70)- CVA.
Review of Systems (ROS): As noted in HPI.
Physical Exam (PE)
VS: BP: 110/70, P: 109, RR: 17, T: 98.9, Weight: 132 lbs., Height 65 inches, BMI 22 kg/m2
• General: Restless, oriented to person and place
• Cardio: S1 and S2 heart sounds in regular rhythm with no murmurs or extra sounds.
• Resp: Lungs CTA, no wheezing or rhonchi. Nonlabored breathing
• Abd: Soft, NT/ND, no masses/HSM, no suprapubic tenderness
• GU: No CVA tenderness, urine dip in office revealed pH 6.0, 3+ leukocytes, positive nitrites
• Ext: Good CMS, no peripheral edema. Attached is a sample of the expectation from this assignment where the desired grade was made on a different patient. Also attached are some case answers/ case notes to use to complete the assignment or reword. Must use template attached, include a introduction, summary, and conclusion after chart complete as shown in sample use case summary info to help but must add made information where missing. This is a SOAP NOTE add in form of the chart.Ext: Good CMS, no peripheral edema
