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Evan Tyson: "Tired and Peeing at Night"
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Evan Tyson: "Tired and Peeing atNight"
Evan Tyson: "Tired and Peeing at Night" iHuman: questions, physical exams, management
plant, problem statement, MSAP, problem categories.
, Student: S.B.
SOAP NOTE # Hank Torrez Patient Initials: (H. T. Male, 39 Y.O.)
I. Subjective Data
A. Chief Complaint (CC): “Tired and peeing at night”
B. History of Present Illness (HPI): Mr. Torrez is 39 y/o married male and active duty in
sale. He presented to the clinic with a cc of “Tired and peeing at night”. He reports
polydipsia with 4L/day of fluid intake, polyphagia with recent weight of 5lbs. and
polyuria with getting up three to four times at night. He also reports blurred vision,
peripheral neuropathy in the soles of his feet, and erectile dysfunction, with
symptoms worsening in the last few months. Pt reports light headiness when getting
up fast . He denies SOB, dyspnea, chest pain, and headaches. Decreased vision,
BMI:29.3. HTN, Hx. of thyroiditis, waist 48''.
C. Last Menstrual Period: (LMP- if applicable): N/A
D. Allergies: NKA
E. Past Medical History: Autoimmune thyroiditis. F. Family History:
Father: myocardial infarction; deceased (age 55).
Mother: Age 60; congestive heart failure; kidney disease (NOS).
Siblings: Sister fairly diagnosed with Diabetes mellitus.
Spouse & offspring: healthy.
Grandparents: N/A
G. Surgery History: None reported
H. Social History: Pt is married and lives with his wife for 19 years. Has two
teenager children, he is active duty living off base and works in sales. Drinks 1-2 beers
on weekends.
Does not smoke or use illicit drugs.
I. Sexual Activity: Yes, active with spouse.
J. Preventive health and health Maintenance:
Up to date on his immunization
Up to date on his health screening Has
been exercising less due to fatigue.
Fast food and snacks on most days K.
Current medications:
Synthroid 75 mcg PO daily
L. Review of Systems (ROS):
• Constitutional (General overall health state): Denies fevers, chills, fatigue, night
sweats. Reports increased fatigue, thirst, appetite, frequent urination, disturbed
sleep, tingling and numbness in feet, and 5lbs. weight loss
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