SOLVED615

Demographics: Age/Gender SUBJECTIVE • CC: HPI: Tim is a 22 y/o male who is complaining of lethargy, cold sensitivity, weight gain of 10 lbs over the last 3 months with an unnoticeable change in appetite, brain fog, constipation, and muscle weakness that he feels has become progressively more noticeable over the last several months. Tim is a heterosexual, single, full-time college student and works part-time at a coffee shop. His last annual physical examination was 2 years ago and was WNL. His current vital signs are 110/70, 62, 98.6, 12, Ht 5’9″ Wt 190 lbs. • • Subjective: (What questions will you ask? Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent). OBJECTIVE General: • VS BP, HR, RR, Weight, Height, BMI • Physical Exam Elements: (Must be listed by System, ONLY as it pertains to Chief Complaint/HPI. Should NOT be all systems or full head to toe unless pertinent.) • POC Testing (any Point of Care (POC) testing specifically performed in the office): What tests (if any) did you perform during the visit (urine dip, rapid strep, urine pregnancy test, Glucose finger-stick, etc.)? Leave
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HEALTH SCIENCE
NURSING

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