Erin Bradley Soap Note 3
Erin Bradley Soap Note 3 SOAP Note #3 3/23/2021 Chief complaint: Nausea and vomiting, feeling shaky and hot along with a flutter in chest 1. Identifying data: Name: Erin Bradley Age: 21 Sex: Female Source: Patient who is a reliable historian. 2. HPI: Ms. Bradley is a 21 years old college student who appears to be moderately distress with complaints of worsening weakness, nausea, vomiting, increase in frequency of bowel movement 3-4 times, hot feeling, heart palpitations, increase appetite, shaky, new onset of productive cough, non-bloody sputum, unintentional weight loss of approximately 10 pounds, insomnia sleeping only 3 hours, oligomenorrhea x 6 months and recently missed one period. In addition, patient reports she recently recovered from the flu and was feeling better then however she started to experience the forementioned symptoms which has progressively got worse impacting her ability to perform her daily routine. Pt also endorses fever in which Tylenol provides some relief and shortness of breath which has gotten worse. She appears anxious denies recreational drug use.
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- November 14, 2022
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- 2022/2023
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