Erin Bradley i-Human Case Study CC: Nausea and Vomiting SOAP Note #3 2023 All the Sections Latest Updates question and Answers

Chief complaint: Nausea and vomiting, feeling shaky and hot along with a flutter in chest 1. Identifying data: Name: Erin Bradley Age: 21 Sex: Female Source: Patient who is a reliable historian. 2. HPI: Ms. Bradley is a 21 years old college student who appears to be moderately distress with complaints of worsening weakness, nausea, vomiting, increase in frequency of bowel movement 3-4 times, hot feeling, heart palpitations, increase appetite, shaky, new onset of productive cough, non-bloody sputum, unintentional weight loss of approximately 10 pounds, insomnia sleeping only 3 hours, oligomenorrhea x 6 months and recently missed one period. In addition, patient reports she recently recovered from the flu and was feeling better then however she started to experience the forementioned symptoms which has progressively got worse impacting her ability to perform her daily routine. Pt also endorses fever in which Tylenol provides some relief and shortness of breath which has gotten worse. She appears anxious denies recreational drug use. 3. ROS: a. General/Constitutional: Pt reports fatigue, insomnia, unintentional weight loss, increase appetite, fever and chills b. HEENT: Pt denies blurry vision, difficulty swallowing/speaking, denies, photophobia, hearing problems or sinus problems. c. Cardiac: Report’s palpitations and decreased exercise tolerance. Denies chest pain d. Respiratory: Reports productive cough and shortness of breath on exertion. Denies wheezing. e. Gastrointestinal: Report’s nausea, vomiting, increase frequency in bowel movement, increase appetite. Denies abdominal pain / f. Genitourinary: Denies hematuria, bladder incontinence, urgency or dysuria. g. Musculoskeletal: Denies muscle or joint pain, muscle cramps, redness, swelling or joint stiffness. h. Neurological: Denies dizziness, fainting, weakness, seizures or tremors. i. Endocrine: Reports increase appetite and heat intolerance. j. Gynecology: Reports Oligomenorrhea and amenorrhea 3. PMH: Flu a. Major Childhood Illness: No major childhood illness reported. c. Current Medications with dosage: Multivitamin 1 tablet by mouth daily.