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-oldSex: MaleSource: PatientAllergies: No known allergies. No seasonal allergies detectedCurrent 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, HypertensionSoap Notes SubjectiveChief 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. ROSGeneral: 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 allergiesCardiovascular: 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. ObjectiveMr. 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 AssessmentHyperthyroidism, a disease related to Graves illnessPlanTo 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
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