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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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