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

Erin Bradley i-Human Case Study CC: Nausea and Vomiting SOAP Note #3 2023 All the Sections Latest Updates question and Answers. SOAP Note #3 3/23/2021 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. Calcium 500mg by mouth daily. Claritin 10mg by mouth daily. Tylenol 650mg by mouth q6h as needed for fever and pain. d. Allergies: Sunflowers (sneeze). e. Surgical procedures/Injuries/Hospitalizations: None. F. Preventative Health: Nutrition: Pt reports 10lbs weight loss verbalizes she has been eating a lot but still loses weight Exercise: Reports inability to exercise due to worsening sob and palpitations f. Immunizations: Up-to-date with all required vaccine for age except flu shot 4. Family history: Father: Hypertension. PGF: Hypertension. 5. Social history: 6. Vitals: Vitals: T 102F, HR 150 regular, R 22, BP supine 160/68, SpO2 94% RA Height: 5’6” Weight: 110 lbs. / BMI: 17.8 7. PHYSICAL EXAM: General appearance: Appears moderately ill, anxious, tremulous, emotionally labile, Alert and oriented x4. Skin: diaphoretic, warm, no rash, no lesions. Eyes: No nystagmus, Perrla, conjunctiva pink no drainage. Mouth: Oral mucous membranes pink and moist. No lesions or ulcers. Neck: Atraumatic, symmetrical, enlarged thyroid with ropey isthmus positive thrill and bruit. Cardiac: Systolic murmur, tachycardic, normal S1/S2, RRR Respiratory: Tachypneic, fine crackles to anterior and posterior RLL, non-productive cough. Chest atraumatic, no tenderness, lumps or masses. Abdomen: Hyp