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Internal Medicine Rotation

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WRITTEN ASSIGNMENT
INTRNAL MEDICINE ROTATION
Name:
Date: 11-04.2018
Rotation specialty: Internal Medicine

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DETAILED SOAP NOTE
SUBJECTIVE
Complete history of presenting Illness (HPI)
Patient name: Mike Ben
Date: 11.04.2018
Referral source: Emergency Department
Chief complaint: State of confusion and shortness of breath for last three days
This is the 1
st
admission for this 42 years old male, who describes that he was in his usual state
of health until three days prior to presenting to the emergency department. Three days ago, he
started to have episodes of shortness of breath and felt to have mental confusion which he told as
being a state of being unsure about what was happening to him. He reports of having the
symptoms of increased thirst, increased urge to eat and waking up at night to pass urine since the
past 1 month but he was not bothered much by these symptoms. However three days ago, as he
woke up from sleep, he felt very weak and fatigued, found it difficult to breathe and felt that he
was not fully alert.
Upon these symptoms, he felt quite upset and visited the emergency department. He is a smoker
and has a sedentary lifestyle. He does not have hypertension or any other active chronic disease.
He has a strong family history of diabetes, both in his father and mother.

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WRITTEN ASSIGNMENT INTRNAL MEDICINE ROTATION Name: Date: 11-04.2018 Rotation specialty: Internal Medicine DETAILED SOAP NOTE SUBJECTIVE Complete history of presenting Illness (HPI) Patient name: Mike Ben Date: 11.04.2018 Referral source: Emergency Department Chief complaint: State of confusion and shortness of breath for last three days This is the 1st admission for this 42 years old male, who describes that he was in his usual state of health until three days prior to presenting to the emergency department. Three days ago, he started to have episodes of shortness of breath and felt to have mental confusion which he told as being a state of being unsure about what was happening to him. He reports of having the symptoms of increased thirst, increased urge to eat and waking up at night to pass urine since the past 1 month but he was not bothered much by these symptoms. However three days ago, as he woke up from sleep, he felt very weak and fatigued, found it difficult to breathe and felt that he was not fully alert. Upon these symptoms, he felt quite upset and visited the emergency department. He is a smoker and has a sedentary lifestyle. He does not have hypertension or any other active chronic disease. He has a strong family history of diabetes, both in his father and mother. Pertinent past medical history 2013 Diagnosed with Generalized Anxiety Disorder and took SSRIs for one year. 2017 Had a fall on to road being hit by a reversing vehicle. Took three months for ...
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