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