SOAP NOTE # Hank Torrez Patient Initials: (H. T. Male, 39 Y.O.)
I. Subjective Data
A. Chief Complaint (CC): “Tired and peeing at night”
B. History of Present Illness (HPI): Mr. Torrez is 39 y/o married male and acti
...
SOAP NOTE # Hank Torrez Patient Initials: (H. T. Male, 39 Y.O.)
I. Subjective Data
A. Chief Complaint (CC): “Tired and peeing at night”
B. History of Present Illness (HPI): Mr. Torrez is 39 y/o married male and active duty in sale. He presented to the clinic with a cc of “Tired and peeing at night”. He reports polydipsia with 4L/day of fluid intake, polyphagia with recent weight of 5lbs. and polyuria with getting up three to four times at night. He also reports blurred vision, peripheral neuropathy in the soles of his feet, and erectile dysfunction, with symptoms worsening in the last few months. Pt reports light headiness when getting up fast . He denies SOB, dyspnea, chest pain, and headaches. Decreased vision, BMI:29.3. HTN, Hx. of thyroiditis, waist 48''.
C. Last Menstrual Period: (LMP- if applicable): N/A
D. Allergies:
NKA
E. Past Medical History:
Autoimmune thyroiditis.
F. Family History:
Father: myocardial infarction; deceased (age 55).
Mother: Age 60; congestive heart failure; kidney disease (NOS). Siblings: Sister fairly diagnosed with Diabetes mellitus.
Spouse & offspring: healthy. Grandparents: N/A
G. Surgery History: None reported
H. Social History: Pt is married and lives with his wife for 19 years. Has two teenager children, he is active duty living off base and works in sales. Drinks 1-2 beers on weekends. Does not smoke or use illicit drugs
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