Chamberlain College of NursingNR 511Week 6 Case Summary

Running Head: CASE PRESENTATION 1 Case Presentation Chamberlain College of Nursing September 2017 CASE PRESENTATION 2 Michael SOAP S: SUBJECTIVE DATA Patient information: age 10, male Caucasian, insurance not spe ...

Running Head: CASE PRESENTATION 1 Case Presentation Chamberlain College of Nursing September 2017 CASE PRESENTATION 2 Michael SOAP S: SUBJECTIVE DATA Patient information: age 10, male Caucasian, insurance not specified Chief Complaint (CC): Reported by his mother, “has not been himself lately, no energy, no appetite, weight loss, increased thirst, sleeping more, and an episode of bed wetting last week”. History of present illness (HPI): This established patient, accompanied today by his mother reports low energy, no appetite, weight loss. Had a cold a few weeks ago, but seems to be getting worse. O- A few weeks ago L- Body fatigue D- Symptoms are continuous, getting worse C- Tired, thirsty, no appetite, sleeping a lot, wet the bed last week, weight loss, dizziness, and exercise intolerance “can’t keep up with the kids in gym class” A- Not specified R- Not specified T- Not specified S- Does not want to play outside, not hungry PMH: Childhood illnesses: None. Adult Illnesses: none. Immunizations: UTD. Surgical History: none. Hospital Stays: none. Current Medications: Daily MVI; no daily prescription medications. Allergies: PCNrash; not specified Food, Environmental. CASE PRESENTATION 3 Family/Social History: Mother reports he is a good student, oldest of 4 children. Lives with his parents, siblings, and grandparents in their home. Has 2 dogs and a cat. Does not drink ETOH, smoke tobacco, or use illicit drugs. Sleeps 8-10 hrs./day. Parents and siblings in good health. MGM: HTN and hyperlipidemia; MGF: HTN and hyperlipidemia. Paternal grandparents deceased; PGM: brain ca, PGF: leukemia. REVIEW OF SYSTEMS: CONSTITUTIONAL: Reports fatigue, weight loss and decreased appetite. HEENT: Head: reports dizziness. Eyes: not specified. Ears: not specified. Nose: not specified; Throat: not specified. Neck: not specified CARDIOVASCULAR: Reports “Cannot keep up with the other kids in gym class” RESPIRATORY: Reports recent cold a few weeks back. GI: Reports weight loss and no appetite GENITOURINARY: Reports recent episode of bed wetting ENDOCRINOLOGIC: Reports always thirsty, sleeps a lot, and fatigue ALLERGIC: PCN-rash