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 has been sick. Increased
...
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 has 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
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