NR 511MMiller.SOAP week 6.docx
Michael 10 years
Subjective
Chief complaint: fatigue; “We have both been usually tired. I have noticed Michael has not been
himself for a few weeks, maybe more.”
History of present il
...
NR 511MMiller.SOAP week 6.docx
Michael 10 years
Subjective
Chief complaint: fatigue; “We have both been usually tired. I have noticed Michael has not been
himself for a few weeks, maybe more.”
History of present illness (HPI):
O: Onset- Approximately a few weeks possibly more
L: Location—Not reviewed
D: Duration-current disposition
C: Characteristics/Associated symptoms- polydipsia, weight loss, bed wetting, sleeping more,
does not want to play out doors, can’t keep up with the other kids in gym class, gets dizzy, never
hungry
A: Aggravating factors- Not reviewed
R: relieving factors- Not reviewed
T: Treatments- Not reviewed
S: Severity-inability to play outdoors and keep up with kids in class
Past Medical History: 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: Parents and siblings are in good health, MGM: HTN and hyperlipidemia. MGF:
HTN and hyperlipidemia. Paternal grandparents deceased: PGM: brain Ca, PGF: leukemia
Social History: Good student, oldest of four children. Lives with parents, grandparents and
siblings. Have 2 dogs and a cat.
Review of Systems:
Neurologic: dizziness, fatigue
Head/Eyes/Ears/Nose/Mouth/Throat:
Integumentary: rash on elbows
Cardiovascular: not reviewed
Respiratory: not reviewed
Genitourinary: bed wetting
Gastrointestinal: not reviewed
Musculoskeletal: not reviewed
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