Soap Hypertension and Depressive Disorder Essay

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.

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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. Soap Hypertension and Depressive Disorder Essay

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

Soap Hypertension and Depressive Disorder Essay