Running head: WEEK 6: SUMMARY 1
Week 6: Case Presentation
Chamberlain University
NR603: Advanced Clinical Diagnosis and Practice Across Lifespan
March 2018
SOAP Week 6
Patient Information:
S.C., 48-year-old female, Caucasian, insurance unknown.
(S) Subjective:
CC: "increasing weight despite dieting"
HPI: 48-year-old white woman complaining of increasing weight gain despite diet over past 4 months.
Has less energy than usual, decreased interest in usual activities, less able to complete routine tasks, and
generally slowed up. Dissatisfied with her overall appearance and inability to lose weight.
Current Medications:
Denies prescription medication. Takes daily multivitamin for last month.
Allergies: NKDA.
PMHx: HTN.
PSHx: Denies past surgeries. Hospitalization for childbirth x2. G2P2.
Childhood Illnesses: None reported.
Immunization Hx: Unsure of immunization status. No recent influenza, tetanus.
Other Screenings: Not reported.
Soc Hx: The patient reported that she had recently quit smoking ‘cold turkey’ and had successfully
maintained abstinence for four months. She reported quitting smoking following the death of her
mother because she died of cancer. She quit smoking without any professional help and without the use
of any nicotine replacements or medications to assist with the smoking cessation. she began smoking at
This study source was downloaded by 100000829050058 from CourseHero.com on 02-10-2022 08:01:06 GMT -06:00
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, WEEK 6: SUMMARY 2
age 18, that she had successfully quit smoking upon becoming pregnant at age 24, but resumed when
she returned to work 11 years ago. She reported a daily smoking frequency of 15 to 20 cigarettes per
day. She reported no serious efforts to stop smoking during the past 11 years prior to this recent period
of complete abstinence.
Lives with husband and children. The patient completed college and a master's degree in education and
had been employed as a special education teacher in the same job for 11 years
Fam Hx: Mother dies of cancer.
ROS:
CONSTITUTIONAL: No reports of fever, chills. Reports a weight gain of 25 pounds in past 6 months.
HEENT: Vision may be less acute, hearing normal, no dizziness.
SKIN: Denies itchiness, rashes or dryness.
CARDIOVASCULAR: Denies chest pain, dyspnea on exercise/at night, swelling ankles.
RESPIRATORY: Denies cough or wheezing.
GASTROINTESTINAL: The patient reported an onset of “eating binges” at approximately age 16. Reports
skipping breakfast, eating a “normal” lunch, eating a dinner with her family. Approximately 30 minutes
after the evening meal and spanning the two hours before bedtime, included: a roll of Ritz crackers
with 6 ounces of cheese, 2 doughnuts, 4 handfuls of Chex mix, and ½ of a large (12 oz.) Cadbury candy
bar. Denies abdominal pain, nausea, vomiting and indigestion. No dark or bloody stools.
GENITOURINARY: None reported.
NEUROLOGICAL: Denies LOC, numbness and tingling.
MUSCULOSKELETAL: None reported.
HEMATOLOGIC/LYMPHATICS: None reported.
PSYCHIATRIC: None reported.
ENDOCRINOLOGIC: None reported.
ALLERGIES: None reported.
O:
Vital signs: B/P 146/92, HR 60, T 98.0F, RR 12.
Height 5’4”, weight 230 pounds
BMI: 39.5
PHYSICAL EXAM
GENERAL: Looks older than age, overweight, well groomed. Intelligent and cooperative.
HEENT: atraumatic, normocephalic, EOMI, PERRLA. Mucosa moist. Neck: Supple with no
masses/tenderness/lymph nodes. Normal thyroid.
This study source was downloaded by 100000829050058 from CourseHero.com on 02-10-2022 08:01:06 GMT -06:00
https://www.coursehero.com/file/35095352/NR603-Week-6-Case-Summarydocx/
Week 6: Case Presentation
Chamberlain University
NR603: Advanced Clinical Diagnosis and Practice Across Lifespan
March 2018
SOAP Week 6
Patient Information:
S.C., 48-year-old female, Caucasian, insurance unknown.
(S) Subjective:
CC: "increasing weight despite dieting"
HPI: 48-year-old white woman complaining of increasing weight gain despite diet over past 4 months.
Has less energy than usual, decreased interest in usual activities, less able to complete routine tasks, and
generally slowed up. Dissatisfied with her overall appearance and inability to lose weight.
Current Medications:
Denies prescription medication. Takes daily multivitamin for last month.
Allergies: NKDA.
PMHx: HTN.
PSHx: Denies past surgeries. Hospitalization for childbirth x2. G2P2.
Childhood Illnesses: None reported.
Immunization Hx: Unsure of immunization status. No recent influenza, tetanus.
Other Screenings: Not reported.
Soc Hx: The patient reported that she had recently quit smoking ‘cold turkey’ and had successfully
maintained abstinence for four months. She reported quitting smoking following the death of her
mother because she died of cancer. She quit smoking without any professional help and without the use
of any nicotine replacements or medications to assist with the smoking cessation. she began smoking at
This study source was downloaded by 100000829050058 from CourseHero.com on 02-10-2022 08:01:06 GMT -06:00
https://www.coursehero.com/file/35095352/NR603-Week-6-Case-Summarydocx/
, WEEK 6: SUMMARY 2
age 18, that she had successfully quit smoking upon becoming pregnant at age 24, but resumed when
she returned to work 11 years ago. She reported a daily smoking frequency of 15 to 20 cigarettes per
day. She reported no serious efforts to stop smoking during the past 11 years prior to this recent period
of complete abstinence.
Lives with husband and children. The patient completed college and a master's degree in education and
had been employed as a special education teacher in the same job for 11 years
Fam Hx: Mother dies of cancer.
ROS:
CONSTITUTIONAL: No reports of fever, chills. Reports a weight gain of 25 pounds in past 6 months.
HEENT: Vision may be less acute, hearing normal, no dizziness.
SKIN: Denies itchiness, rashes or dryness.
CARDIOVASCULAR: Denies chest pain, dyspnea on exercise/at night, swelling ankles.
RESPIRATORY: Denies cough or wheezing.
GASTROINTESTINAL: The patient reported an onset of “eating binges” at approximately age 16. Reports
skipping breakfast, eating a “normal” lunch, eating a dinner with her family. Approximately 30 minutes
after the evening meal and spanning the two hours before bedtime, included: a roll of Ritz crackers
with 6 ounces of cheese, 2 doughnuts, 4 handfuls of Chex mix, and ½ of a large (12 oz.) Cadbury candy
bar. Denies abdominal pain, nausea, vomiting and indigestion. No dark or bloody stools.
GENITOURINARY: None reported.
NEUROLOGICAL: Denies LOC, numbness and tingling.
MUSCULOSKELETAL: None reported.
HEMATOLOGIC/LYMPHATICS: None reported.
PSYCHIATRIC: None reported.
ENDOCRINOLOGIC: None reported.
ALLERGIES: None reported.
O:
Vital signs: B/P 146/92, HR 60, T 98.0F, RR 12.
Height 5’4”, weight 230 pounds
BMI: 39.5
PHYSICAL EXAM
GENERAL: Looks older than age, overweight, well groomed. Intelligent and cooperative.
HEENT: atraumatic, normocephalic, EOMI, PERRLA. Mucosa moist. Neck: Supple with no
masses/tenderness/lymph nodes. Normal thyroid.
This study source was downloaded by 100000829050058 from CourseHero.com on 02-10-2022 08:01:06 GMT -06:00
https://www.coursehero.com/file/35095352/NR603-Week-6-Case-Summarydocx/
