NR 511 Week6 SOAP

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NR511 Week6 SOAP NOTE Michael S: SUBJECTIVE DATA Chief Complaint (CC): “unusually tired” History of present illness (HPI): A few weeks ago came down with the cold. Everyone in the family h... as been sick. Increased tiredness over that time. Lack of appetite and has lost weight. Always thirsty and has wet the bed last week. Past Medical History (PMH): Age 10. Mother reports general health as good: no childhood or chronic illnesses. Surgeries: none. Hospitalizations: none. Immunizations: UTD: allergies: Penicillin, gets a rash no ETOH, tobacco, illicit drugs. Sleeping 8-10 hours a night. Medications: daily multivitamin Family History (FH): Parents and siblings are in good health, Maternal grandmother: HTN and hyperlipidemia. Maternal grandfather: HTN and hyperlipidemia. Paternal grandparents deceased: Paternal grandmother: brain Ca, Paternal grandfather: leukemia Social History(SH): Good student, oldest of four children. Lives with parents, grandparents and siblings. Has 2 dogs and a cat. Review of Systems (ROS). General: (-) fever, (-) chills, (+) fatigue (-) nausea, (-) vomiting Ears: (-) pain Nose: (-)nasal congestion, (-) discharge Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness Respiratory: (-) Shortness of breath, (-)wheezes Gastrointestinal: (-) heartburn, (-) indigestion Lymphatics: (-) swelling 0: OBJECTIVE DATA Constitutional: alert, oriented and cooperative VS: Height: 48 inches weight 78 pounds BP 110/70 T 98.2 P 65 R 16.BMI: 23.8 General: Alert and cooperative, appears tired and distracted. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact [Show More]

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