NR 511 Week 6 SOAP NOTE Michael
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
m
er as
hyperlipidemia. Maternal grandfather: HTN and hyperlipidemia. Paternal grandparents deceased:
co
Paternal grandmother: brain Ca, Paternal grandfather: leukemia
eH w
Social History(SH): Good student, oldest of four children. Lives with parents, grandparents
o.
rs e
and siblings. Has 2 dogs and a cat.
ou urc
Review of Systems (ROS).
General: (-) fever, (-) chills, (+) fatigue (-) nausea, (-) vomiting
o
aC s
Ears: (-) pain
vi y re
Nose: (-)nasal congestion, (-) discharge
Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness
ed d
ar stu
Respiratory: (-) Shortness of breath, (-)wheezes
Gastrointestinal: (-) heartburn, (-) indigestion
is
Lymphatics: (-) swelling
Th
0: OBJECTIVE DATA
Constitutional: alert, oriented and cooperative
sh
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
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:32:41 GMT -05:00
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, with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses
nontender to palpation.Throat: Oropharynx dry, no lesions or exudate. Tonsils ¼ bilaterally.
Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness
noted. Thyroid midline, small and firm without palpable masses.
Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Lungs clear
to auscultation bilaterally. Respirations unlabored.
Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or
skin changes.
Abdomen: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted.
Musculoskeletal: reflexes WNL. Gait steady.
Testing Results:
m
er as
CBC: WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5
co
eH w
Fasting glucose 136 mg/dL
o.
TSH: 2.6 mIU/L free T4 15 pmol/L
rs e
ou urc
A: ASSESSMENT:
o
1: Hypergylcemia (ICD-10 R73.9)- is an abnormally high blood glucose level as a result of beta
aC s
cell destruction (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Common symptoms
vi y re
include polyuria, polydipsia, polyphagia, nocturnal enuresis, anorexia, weakness, fatigue, blurred
vision, and vision changes (Dunphy et al., 2015).
ed d
ar stu
P: PLAN
1. Medications: No treatment until secondary confirmation (Pippitt & Gurgle, 2016).
is
Th
2. Additional diagnostic tests. Hemoglobin A1C greater than or equal to 6.5% or another repeat
fasting glucose greater than 126 mg/dl are needed to confirm diagnosis (Pippitt & Gurgle, 2016).
Another confirmation would be a random glucose of greater than 200mg/dl with signs and
sh
symptoms of diabetes (Pippitt & Gurgle, 2016). EKG, urinalysis, fasting lipid profile, liver
enzyme, and microalbuminuria (Dunphy et al., 2015).
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:32:41 GMT -05:00
https://www.coursehero.com/file/23906554/NR511-Week6/
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
m
er as
hyperlipidemia. Maternal grandfather: HTN and hyperlipidemia. Paternal grandparents deceased:
co
Paternal grandmother: brain Ca, Paternal grandfather: leukemia
eH w
Social History(SH): Good student, oldest of four children. Lives with parents, grandparents
o.
rs e
and siblings. Has 2 dogs and a cat.
ou urc
Review of Systems (ROS).
General: (-) fever, (-) chills, (+) fatigue (-) nausea, (-) vomiting
o
aC s
Ears: (-) pain
vi y re
Nose: (-)nasal congestion, (-) discharge
Cardiovascular: (-) chest pain, (-) palpitation, (-) dizziness
ed d
ar stu
Respiratory: (-) Shortness of breath, (-)wheezes
Gastrointestinal: (-) heartburn, (-) indigestion
is
Lymphatics: (-) swelling
Th
0: OBJECTIVE DATA
Constitutional: alert, oriented and cooperative
sh
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
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:32:41 GMT -05:00
https://www.coursehero.com/file/23906554/NR511-Week6/
, with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses
nontender to palpation.Throat: Oropharynx dry, no lesions or exudate. Tonsils ¼ bilaterally.
Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness
noted. Thyroid midline, small and firm without palpable masses.
Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Lungs clear
to auscultation bilaterally. Respirations unlabored.
Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or
skin changes.
Abdomen: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted.
Musculoskeletal: reflexes WNL. Gait steady.
Testing Results:
m
er as
CBC: WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5
co
eH w
Fasting glucose 136 mg/dL
o.
TSH: 2.6 mIU/L free T4 15 pmol/L
rs e
ou urc
A: ASSESSMENT:
o
1: Hypergylcemia (ICD-10 R73.9)- is an abnormally high blood glucose level as a result of beta
aC s
cell destruction (Dunphy, Winland-Brown, Porter, & Thomas, 2015). Common symptoms
vi y re
include polyuria, polydipsia, polyphagia, nocturnal enuresis, anorexia, weakness, fatigue, blurred
vision, and vision changes (Dunphy et al., 2015).
ed d
ar stu
P: PLAN
1. Medications: No treatment until secondary confirmation (Pippitt & Gurgle, 2016).
is
Th
2. Additional diagnostic tests. Hemoglobin A1C greater than or equal to 6.5% or another repeat
fasting glucose greater than 126 mg/dl are needed to confirm diagnosis (Pippitt & Gurgle, 2016).
Another confirmation would be a random glucose of greater than 200mg/dl with signs and
sh
symptoms of diabetes (Pippitt & Gurgle, 2016). EKG, urinalysis, fasting lipid profile, liver
enzyme, and microalbuminuria (Dunphy et al., 2015).
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:32:41 GMT -05:00
https://www.coursehero.com/file/23906554/NR511-Week6/
