SU_NSG6440_week 6 soap_ech

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School

South University, Savannah *

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Course

6440

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Medicine

Date

Feb 20, 2024

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docx

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Name: DA Pt. Encounter Number: 4586 Date: 12/6/2021 Age: 42 Sex: Male SUBJECTIVE CC: “ I have this cut on right ankle that won’t heal, I’m always tired and I have to pie often even at night, now even my vision gets blurry, and I’ve been losing weight ” HPI: Patient is a 42-year-old Mexican American male complaining of increased thirst, frequent urination, hunger, fatigue, and blurred vision, paresthesia and these symptoms started about 2-3 months ago he states about a year ago he was told that he was pre diabetic and just never follow up until now due to lack of insurance. He also sustained a cut more than a week ago to his right ankle that is not healing, he has used OTC antibiotic ointment and states he keeps it clean. He denies any other disease and illness outside of common cold, he has not had surgery. Patient also reports feeling that he lost weight because his close does not fit him the same. The last time patient saw a provider was over a year ago, he recently moved to area due to his new job and wants to establish care now that he has health insurance. Medications: OTC antibiotic ointment for cut to r ankle uses prn PMH Allergies: NKDA, denies food and environmental allergies Medication Intolerances: denies Chronic Illnesses/Major traumas: None Hospitalizations/Surgeries Patient denies history of HTN peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis, have been advise about a year ago he was pr diabetic Family History Mother 68 alive lives in Mexico with Hx of HTN and Diabetes Type II Father 70 alive lives in Mexico with a HX of CAD Sister 38 alive with no significant hx Sister 35 dx with HTN after first child at age 28 No one in his family have psychiatric illnesses cancer, TB, lung disease Social History Patient is married with 5 children ages 2-11, living with his wife of 12 years, he drinks 1- 2 beers daily, he works construction and smokes about ½ pack of cigarette daily, he denies smoking in the home and states he adheres to safety measures when at work and

on the road. He denies substance use and marijuana use. ROS General Fatigue and weight lost, and low energy levels And weight lost Cardiovascular No chest pain, palpitations, PND, orthopnea, and edema Skin Delayed healing to r ankle abrasion for longer than 10 days, no rashes, bruising, bleeding or skin discolorations, and any lesions or moles Respiratory No cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB Eyes Blurred vision for 2-3 months, do not wear glasses or corrective lenses Gastrointestinal No abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools Ears No ear pain, hearing loss, ringing in ears, and discharge Genitourinary/Gynecological Urgency and frequency, no burning, urinary complaints of waking up at night to urinate Nose/Mouth/Throat No Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain Musculoskeletal No Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis Breast No SBE, lumps, bumps, or changes Neurological No Syncope, seizures, transient paralysis, increased weakness and paresthesia, no black-out spells Heme/Lymph/Endo HIV status is negative, no bruising, no blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric No depression, anxiety, some sleeping difficulties due to awakening frequently to urinate, no suicidal ideation/attempts, and previous dx OBJECTIVE Weight 195 BMI 29.6 Temp 97. BP 130/82 Height 5’8 Pulse 99 Resp 22

General Appearance Patient appears fatigue, well dress alert and oriented with appropriate answer to questions Skin Cardiovascular Respiratory Gastrointestinal Breast Exam deferred Genitourinary Musculoskeletal Neurological

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