SU_NSG6420_W8_A4_Taylor_A.docx - SOAP NOTE Name AS Date Age 51 Time 8:30 Sex M SUBJECTIVE CC AS is a 51-year-old African-American male who presented for

SU_NSG6420_W8_A4_Taylor_A.docx - SOAP NOTE Name AS Date Age...

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SOAP NOTE Name: AS Date: 12/17/18 Time: 8:30 Age: 51 Sex: M SUBJECTIVE CC: AS is a 51-year-old African-American male who presented for weakness, polyuria, polydipsia, vision changes, and increased appetite with weight loss for the last two months. HPI: Pt states that ‘I am getting up two or three times a night to urinate. I’m thirsty at those times so I drink a glass of water each time”. Pt also reports that he has gradually gained weight over the years and is minimally active. Pt reports pain in his feet that is “worse at night and keeps me awake” The pain is noted to be burning in nature with numbness in his toes. HE also reports numbness and tingling in his fingers that is causing problems in his job as a mechanic. Pt states that his vision “is blurry at times, especially in the afternoon”. Medications: No prior medications PMH Allergies: NKA Medication Intolerances: None Chronic Illnesses/Major traumas: None
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Hospitalizations/Surgeries: Appendectomy in 1978 Family History Both of AS’s parents are deceased. His father died at age 72 from a stroke. His mother died at age 70 from end-stage kidney disease related to diabetes for which she was diagnosed at 50. AS is the youngest of three
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  • Summer '16
  • ANDREWCLARK
  • Diabetes

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