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APA stile, no plagiarism. This is an example of SOAP notes: Patient Information Name: Mr. R.G. Age: 58-year-old Sex: Male Source: Patient Allergies: No known allergies. No seasonal allergies detected
APA stile, no plagiarism. This is an example of SOAP notes:
Patient Information
Name: Mr. R.G.
Age: 58-year-old
Sex: Male
Source: Patient
Allergies: No known allergies. No seasonal allergies detected
Current Medications: No current medication mentioned by the patient.
PMH: The patient has been abusing alcohol but quit two years back. He is suffering from obesity disorder and hypothyroidism.
Immunizations: Immunization is up to date.
History of the Family: Mother- deceased at 70 years, no information related to the cause of his death but was having obesity disorder.
Father still alive: History of Type II diabetes, Hypertension
Soap Notes
Subjective
Chief Complain (CC): the patient came to the facility complaining of heat intolerance, and sweating.
HPI: Mr. R.G he is having an increased nervousness, sweating, and hotness of the body.
ROS
General: Patient appears to be weak and fatigue. He has a loss in the body weight, poor sleep, thirst, nausea, and increased frequency of defection. He also states of losing appetite and shaking.
Constitutional: The patient denies of having chest pain, palpitations, shortness of breath, and disorientation.
Respiratory: No shortness of breath with no asthma or seasonal allergies
Cardiovascular: no history of Dyslipidemia, no history of high blood pressure. He has no dyspnea on exertion, there is absent of cough, edema, or heart murmurs.
Gastrointestinal: the patient has nausea but no vomiting. The patient has lost appetite.
GU: He denies vaginal discharge, no irritation in his urinary tract.
Objective
Mr. R.G appears to be little disturbed, maintains his eye contact, clearly gives a proper description of how he feels and his age, and the dressing as per the present weather.
Vital Signs: B/P: 105/95 mmHg, Regular pulse of 90 beats per min, Temprature: 96.5; Height: 70 inches; weight: 113 lb: BMI: 16.2.
Clear and normal breathing sounds with no adventitious breathing sounds. Goiter noted on palpation.
Cardiovascular: no apparent distress, fidgeting in the seat, no presence of murmurs and gallops.
Gastrointestinal: soft and non-tendered abdomen when touched.
GU: suprapubic regions are tender to touch
Assessment
Hyperthyroidism, a disease related to Graves’ illness
Plan
To acquire the baseline thyroid stimulating hormone assay; prescription of the antithyroid medications such as Carbimazole and propylthiouracil; performing thyroid hormone level using thyroid stimulating hormone blood test.; monitoring the thyroid-stimulating hormone assay at first and the third months, performing radioactive iodine treatment when necessary. In case the thyroid hormone level is not improved, thyroid lobectomy will be performed
