[identity profile] umbo.livejournal.com posting in [community profile] ds_flashfiction
This thing hit me this morning--woke up to pee, couldn't get back to sleep until I wrote it. Beta thanks to [livejournal.com profile] ckr and [livejournal.com profile] ardent_muses.



Note: SOAP is how health care providers are trained to organize their notes for a patient/client. S stands for Subjective, or the things the client tells you, like their complaints and their medical history. O stands for Objective, or the actual physical findings of the exam. A stands for Assessment, which is the conclusion you draw (e.g. this client may have diabetes), and P stands for Plan, or what you're going to do about it (e.g. send them for a glucose tolerance test). WNL stands for "within normal limits," HTN is hypertension, and DM is diabetes. Not that knowing any of that is really important ;-)

SOAP Note

Pt's Name: Ray Kowalski MR# 966534
7/12/03 4:30 pm

S: 43 yo WM presents for annual physical. Denies probs/questions.
Med. Hist.: Usual childhood diseases. + frostbite L great toe 1998, no amputation. + broken arm age 8; broken nose age 20; gunshot to abdomen, 1989; dogsled accident 2000 (stitches R leg, no broken bones).
Surg: Abdominal (remove bullet) 1989, no complications, no probs. with anesthesia.
Hosp: 1989, see above.
Fam. Hist.: + HTN (F, PGF, PGM), + prostate cancer (MGF), + breast cancer (MGM), + DM (PGM), + osteoarthritis (PGF, PGM, MGM).
Social Hist.: Imm. from US in 1998 to be with current partner, who is RCMP officer. Works in snowmobile repair and "odd jobs." Former police officer. Ed: 14 years. Divorced; going to Toronto in 2 wks to marry current (m) partner.
Sex. Hist: Bisexual; has been with current partner x 5 yrs. Uses condoms. States he and partner have both been tested and are HIV negative.
Denies phys/sex abuse.
Allergies: NKMA; environmental (cats).
Exercise: dogsledding, snowshoeing, walking.
Denies smoking/drugs, states occ. beer.
Meds: Occ. ibuprofen or tylenol; states occ. uses salve made by partner for sore muscles/joints.
24 hour diet recall: coffee with smarties, cereal with milk, pizza. States eats better when partner is not on patrol.

O: BP 126/74, P 85, T 97.9 oral, RR 16
Ht: 5'11 Wt: 160 BMI 22
Gen'l: Pleasant, thin, no apparent distress.
HEENT: Wears glasses, otherwise WNL, no thyromegaly, no lympadenopathy. Teeth in good repair.
Heart: RRR; S1, S2; no murmur.
Lungs: Clear to auscultation, resp. easy & unlabored.
Neuro: Grossly intact; reflexes +3 bilat.
Skin: Pink, warm; scar L great toe, R thigh, lower R abdomen. No varicosities. Tattoos R shoulder, L hip.
Abd: NT, no organomegaly. Surgical/gunshot scar well approximated, no keloids.
Back: No scoliosis, - CVAT.
Extremities: Normal ROM; - Homan's; + crepitus bilat. knees. No clubbing of fingers, capillary refill <3 sec.
Genitalia: Normal male, testes non-enlarged, symm., no masses, no hydrocele.
Rectal: prostate NT, non-enlarged; guaiac -.

A/P: Phys. exam WNL except mild arthritis both knees.
Advised cont. weight bearing exercise, good diet, incr. protein and calcium intake, importance of incr. intake in this climate. Given info on testicular self-exam, revised food pyramid. Advised biannual PSA due to family history of prostate cancer.
Labs: PSA, CBC, lipid profile.
RTC 1 year and prn.

--C. Maclean, NP, MS

Date: 2003-06-21 02:24 pm (UTC)
From: [identity profile] mei-x.livejournal.com
I really like this choice of document. It's very clinical, yet so revealing about Ray's life.
(deleted comment)

Date: 2003-06-21 02:52 pm (UTC)
ext_3548: (got  lube)
From: [identity profile] shayheyred.livejournal.com
Verrrrry interesting.

Does anyone else want to know what the tattoo on his left hip is???

(Hey - I just shot the guy in his leg; you shot him in the stomach. Meanie.)

Date: 2003-06-21 03:53 pm (UTC)
From: [identity profile] ardent-muses.livejournal.com
Personally, I think "hip" is a euphemism. *G*

He's got a maple leaf on his ass.

Loved this.
(deleted comment)

Date: 2003-06-22 07:44 pm (UTC)
From: [identity profile] jack-pride.livejournal.com
Not that I'm saying they *shouldn't* move to Canada, Canada being the rockin' place that it is, but I just thought I'd point out that Canada has no residency requirements for marriages; your son and his partner could just go take a vacation-cum-honeymoon and get married while they're there. :)

Date: 2003-06-21 03:41 pm (UTC)
From: [identity profile] cesperanza.livejournal.com
Love this--the expertise really shows, both medical and literary (the tattoo on the hip! Says so much in an offhand way! and I agree with everyone that you've constructed a body that makes so much sense in terms of the character and lifestyle--not easy to do!) Wonderful snapshot of Ray, kind of from an xray perspective. *g*

Date: 2003-06-21 04:43 pm (UTC)
ext_12460: acquired from fanpop.com (Default)
From: [identity profile] akite.livejournal.com
Wow! Mine is going to look so mundane when I post it. ;) Very interesting, Shell. I read it though twice just to make sure I got it all. ::g::

Date: 2003-06-21 07:44 pm (UTC)
From: [identity profile] dirty-diana.livejournal.com
I was thinking that a medical history of one of the guys would be very revealing, but I didn't have the knowledge necesary to pull it off. So I'm glad someone did. Nice job.

Date: 2003-06-21 08:14 pm (UTC)
ext_3579: I'm still not watching supernatural. (Default)
From: [identity profile] the-star-fish.livejournal.com
Really nice job, sweetie. Glad you stayed up to write it!

Date: 2003-06-21 10:47 pm (UTC)
From: [identity profile] ozsaur.livejournal.com
This is fascinating. I always wonder what the doctor or nurse is writing in the chart. They never let you peek. This is a cool snapshot of Ray.

nifty stuff

Date: 2003-06-22 09:22 am (UTC)
From: [identity profile] kormantic.livejournal.com
Slash plus learning... It's diabolically nutritious! :) Very nice.

Date: 2003-06-22 11:01 am (UTC)
From: [identity profile] bluster.livejournal.com
Way to make an entrace, Shell! I had to laugh when I read the bit about his genitalia. Somehow I think Ray would take exception to having them referred to as "normal." :-)

I hope this means you're going to be writing more dS. :-)

Date: 2003-06-22 07:47 pm (UTC)
From: [identity profile] jack-pride.livejournal.com
It's *definitely* a maple leaf tattoo. No doubt about it. But I think I like the frostbite detail best, since it means he got to go looking for the Hand of Franklin.

And the Smarties in his coffee. Because Smarties are *so* much better than M&Ms!

Date: 2003-06-23 07:49 am (UTC)
From: [identity profile] rowanfairchild.livejournal.com
So cool, Shell! Love the evaluation of Ray. I have a special fondness for pieces where the writer treats the characters as real people, lends such a wonderful roundness to them. Glad you couldn't sleep! *g*

Date: 2006-01-22 04:15 am (UTC)
From: [identity profile] dr-dredd.livejournal.com
This was great! Loved the 24 hour diet recall.

Date: 2007-02-26 08:32 pm (UTC)
From: [identity profile] shoemaster.livejournal.com
I look at these things all through out work, (they've changed the format some but *handwave*) and NONE of them make me quite so happy as this. I've always loved outsider POV on the boyfriends, and this is a step even beyond that. This nurse is just documenting Ray's current life with Fraser and you can see the ways that Fraser is good for him and they're getting maaaaaaaaaarried. *sigh*

Date: 2007-03-11 08:05 pm (UTC)
From: [identity profile] raveninthewind.livejournal.com
Hey, somehow I didn't comment when I read this before. I thought you did a wonderful job of giving us information from the outsider's POV.

Date: 2009-06-22 08:06 pm (UTC)
From: [identity profile] magicalmongoose.livejournal.com
Hee, cool! I'm still a bit creeped out by the apparent breaking of doctor/patient confidentiality (even though this is not a real person and you're not really his doctor), but I love the idea of medical charts as fic. I'll have to try my hand at one and see what I can come up with! It'll be good practice for when I hit the hospital in a few weeks as a med student...

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