FNP 592 Week 5 SOAP Note Clinical Documentation

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Clinical Documentation

Student Name and clinical course:  Ali Junayed FNP 592

Client’s Initials*: XX            Age: 14    Race: Hispanic    Gender: Female Date of Birth: January 1, 2017 Insurance: No   Marital Status: Unmarried

Subjective:

CC: Fatigue prevents me from doing my everyday activities.

HPI: A 15-year-old Hispanic girl complains of fatigue for a month in the workplace. No matter how much she slept, she was too exhausted to accomplish her responsibilities. She had no triggers today. She lacks focus at school and cannot learn. Her appetite has decreased lately, although she has not lost weight.  

Past Medical History:

• Medical problem list: None.
• Preventative care: Up-to-date vaccinations
• Surgeries: None

• Hospitalizations: None
• LMP, pregnancy status, menopause, etc. for women: LMP was 2.5 weeks ago, regular cycle.

Allergies: NKDA 

Medications: N/A

Family History: Non-contributory family history.

Social History: XX is a tenth-grader. Her mom and siblings live there. She denies smoke, alcohol, and drug usage. Sexually inactive. She claims to have a good sleep schedule and no new problems. 

ROS

CONSTITUTIONAL: Weight loss. Absence of pyrexia and rigors..

HEENT: Absence of symptoms such as visual impairment, ear pain, sinus blockage, and throat discomfort.

NECK: No presence of lymphadenopathy reported..

RESPIRATORY: No evidence of dyspnea with exertion. Absence of cough, dyspnea, and wheezing..

CARDIAC: No chest discomfort seen. Absence of vibrations and dizziness..

GASTROINTESTINAL: Exhibiting reduced appetite, detrimental to feeling full early, and excessive flatulence. Reports the absence of symptoms such as nausea, diarrhea, constipation, and stomach discomfort.

BREAST: No presence of gynecomastia reported.

GENITOURINARY: The individual reports no symptoms of painful urination, frequent urination, or blood in the urine.

EXTREMITIES: The patient reports no swelling in the limbs and no decrease in feeling.

SKIN: No reports of pruritus or dermatitis.

MUSCULOSKELETAL: No reported symptoms of bone or joint discomfort and muscle soreness.

NEUROLOGIC: No reported occurrences of headaches, convulsions, dizziness, numbness, or tingling.

PSYCHIATRIC: No presence of anxiety or sadness.

 Objective

Vital Signs:   HR -88      BP – 125/87      Temp- 98 RR-19       SpO2- 98%           Pain- 7/10

Height-72 inches     Weight- 189 lbs      BMI- 25.63

Labs, radiology, or other pertinent studies: Thyroid test and CBC

Physical Exam

CONSTITUTIONAL: Well-developed, no apparent distress, and appears stated

age.

HEENT: Normocephalic, atraumatic.

PERRLA/EOMI. No nasal discharge or sinus tenderness. Moist mucous membranes. The

oropharynx is clear, with no erythema or exudates. NECK: Supple, symmetrical, trachea midline.

No palpable lymphadenopathy.

RESPIRATORY: Clear to auscultation. Good air movement. 

CARDIAC: Regular rate and rhythm. Standard S1 and S2. No S3 or S4. No murmurs, rubs, or

gallops.

GASTROINTESTINAL: Hyperactive bowel sounds. Soft, non-distended, non-tender. No

palpable hepatosplenomegaly.

EXTREMITIES: No swelling, tenderness, discolouration, or peripheral oedema. 

SKIN: No rashes.

MSK: Strength and ROM are grossly intact and symmetrical.

NEUROLOGIC: Sensation to light touch is grossly intact throughout.

PSYCHIATRIC: Appropriate mood and affect.

Assessment

Differentials:

• Anaemia: Iron deficiency causes tiredness. It may diminish appetite and impair concentration (Mayo Clinic, 2022). CBC tests can rule out this condition.

• Thyroid Dysfunction: Fatigue, attention issues, and weight fluctuations might result from hypo or hyperthyroidism (Cleveland Clinic, 2020). A thyroid function test helps evaluate thyroid function.

• Psychological Causes: Stress, worry, and depression may cause tiredness, weight, and hunger changes.  

Diagnosis: 

Fatigue: Chronic weariness affects the patient’s weight and appetite. A specific stressor event or other circumstances might cause it. Extreme weariness might impair focus.

Plan

Diagnostics:

1. CBC
2. CMP
3. Psychological evaluation.
4. Thyroid function tests (National Guideline Centre (UK), 2019).

Treatment:

1. Dietary modification (Baik & Bird, 2022).
2. Lifestyle changes.

Education

1. Teaching stress-reduction.
2. Teaching the importance of a healthy lifestyle for health.

Follow Up

Schedule the patient back in 4 weeks for reassessment. 

References

Baik, D., & Bird, K. (2022). Dietary Lifestyle Changes. Pub-med; Stat-pearls publishing. https://www.ncbi.nlm.nih.gov/books/NBK587401/

Cleveland Clinic. (2020, April 19). Thyroid Disease: Hypothyroidism & Hyperthyroidism | Cleveland Clinic. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8541-thyroid-disease

Mayo Clinic. (2022, February 11). Anaemia – symptoms and causes. Mayo clinic. https://www.mayoclinic.org/diseases-conditions/anemia/symptoms-causes/syc-20351360

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