Soap Note: Symptoms Are Usually Felt Throughout The Day

Soap Note
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July 20, 2017
SOAP NOTE:
Subjective: The patient is a 70-year-old male complaining of headaches, fatigue, and blurred vision.
The symptoms are usually felt throughout the day, with scattered incidences. It started
five days ago and is occasionally also experiencing frequent thirst or hungriness during the night, despite finishing a meal just a few hours before. Urinations have also been frequent with the patient, going to the bathroom for twice or thrice during the night. As for the headaches, the patient rated it with a 5/6, on a scale of 1-10.
Family Hx – His brother died of Diabetes three years ago. Mother died due to heart attack, and his father died of Alzheimer’s.
Social Hx- Married, retired, but worked at a fast-food chain downtown. Often takes his car to anywhere he goes. Walks rarely. Drinks and smokes
ROS – Rashes w/c are always itchy. Anxiousness about frequent feelings of fatigue and blurred vision.
Objective: Vital Signs: BP 130/85 P 50 bpm R 16 breaths T 99.5°F Blood glucose: 140mg/dl
The patient is friendly, but seems anxious. He might/might not be in distress.
HEENT- pupils round reactive to light. No scleroicteris and has moist
mucous membranes. Signs of lymphatonopathy and bruits are not present.
Little wheezing on auscultation. Resonant to percussion.
Cardiac – regular rhythm, but higher rate than normal. No murmurs or gallops
Abdominal – No surgical scars. Normal active bowel sounds in all four
quadrants. No bruits heard in abdominal aorta, renal arteries, or iliac arteries. Slight abdominal bloating. Liver is a little bit enlarged but spleen is not. He had no rebound tenderness or guarding.
Extremities/musculoskeletal – 2+ radial and dorsalis pulses no clubbing or cyanosis or
edema. Full range of motion in her shoulders, elbows, hands, hips, knees and ankles