*NURSING > SOAP NOTE > Chamberlain College of Nursing NR 511 MMiller.SOAP week 6 Michael 10 years (All)

Chamberlain College of Nursing NR 511 MMiller.SOAP week 6 Michael 10 years

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Michael 10 years Subjective Chief complaint: fatigue; “We have both been usually tired. I have noticed Michael has not been himself for a few weeks, maybe more.” History of present illness (HP... I): O: Onset- Approximately a few weeks possibly more L: Location—Not reviewed D: Duration-current disposition C: Characteristics/Associated symptoms- polydipsia, weight loss, bed wetting, sleeping more, does not want to play out doors, can’t keep up with the other kids in gym class, gets dizzy, never hungry A: Aggravating factors- Not reviewed R: relieving factors- Not reviewed T: Treatments- Not reviewed S: Severity-inability to play outdoors and keep up with kids in class Past Medical History: 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: Parents and siblings are in good health, MGM: HTN and hyperlipidemia. MGF: HTN and hyperlipidemia. Paternal grandparents deceased: PGM: brain Ca, PGF: leukemia Social History: Good student, oldest of four children. Lives with parents, grandparents and siblings. Have 2 dogs and a cat. Review of Systems: Neurologic: dizziness, fatigue Head/Eyes/Ears/Nose/Mouth/Throat: Integumentary: rash on elbows Cardiovascular: not reviewed Respiratory: not reviewed Genitourinary: bed wetting Gastrointestinal: not reviewed Musculoskeletal: not reviewed [Show More]

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