Patient Initials: R.T. Age: 35 years old Race: White Gender: Male
SUBJECTIVE DATA:
Chief Complaint (CC): “I have been having frequent urination and fatigue for past few weeks.”
History of Present Illness (HPI): R.T. is a 35-year-old white male who has visited the community clinic unaccompanied. The patient reports that his reason for visiting the clinic today is to get assistance with the problem of frequent urination accompanied by fatigue. R.T. denies sore throat, persistent cough, or a headache. These symptoms began about 2 weeks ago and they seem not to go away. Besides, he feels extremely thirsty better parts of the day. His daily diet comprises of sandwiches with milk and sugar for breakfast. He also reports eating a lot of potato chips for lunch while at work and carbohydrate-rich foods with vegetables for dinner.
Location: Urinary system.
Onset: 2 weeks ago.
Characteristic/Quality: Frequent urination.
Associated symptoms: Fatigue and extreme thirst.
Timing: The frequency of urination is higher at night than during the day.
Exacerbating or relieving factors: None reported.
Severity or quantity: Quality of urine exceeds usual amount.
Medications: None
Allergies: No known drug or food allergies reported.
Past Medical History (PMH): Hypertension.
Past Surgical History (PSH): Denies surgical history.
Significant Family History: Maternal grandfather has diabetes, died at age 85yrs. Parents- HTN.
Sexual/Reproductive History: R.T. is sexually active and he is happily married with two children, a girl and a boy. He denies have extra-marital affairs.
Personal/Social History: R.T. is an accountant at a coffee factory in the community. He walks to work every day because the factory is near his current place of residence. R.T. denies cigarette and alcohol use. He is a Christian who goes to the church every Sunday. His daily diet comprises of sandwiches with milk and sugar for breakfast. He also reports eating a lot of potato chips for lunch while at work and carbohydrate-rich foods with vegetables for dinner. He occasionally eats meat.
Immunization History: Immunization records indicate that R.T. received all immunizations at the recommended ages.
General: R.T. has reported a slight reduction in body weight since he started to experience his current symptoms a week ago. He feels fatigues, especially during the day when the sun is hot. He denies fever, nausea, or vomiting.
Head: Denies physical head injury. Does not report a headache.
Eyes: Reports a blurry vision during hot weather.
Ears: Denies ear and hearing problems.
Nose: Denies a runny nose, sneezing, or nasal congestion.
Throat: Denies a sore throat.
Neck: Denies pain or swelling in the neck region.
Respiratory: Denies tightness of the chest. Denies breathing difficulties. Denies having pain on the chest.
Cardiovascular/Peripheral Vascular: Denies chest tightness.
Gastrointestinal: No stomachache, no constipation, no abdominal pain.
Genitourinary: Does not report pain in the genitals. No vaginal itching. No pain during urination. Denies abnormal vaginal discharge. Reports increased urination frequency.
Musculoskeletal: Does not report joint pain. Reports fatigue.
Neurologic: Denies headache. Does not report numbness on fingers and toes.
Psychiatric: Denies occasional seizures, issues with memory, or feelings of hopelessness.
Skin: Denies itchiness or redness on the skin. No skin rashes reported.
Hematologic: Does not report anemia or any other blood-related disorders.
Endocrine: Reports extreme thirst. Reports frequent urination. Reports an increase in urine volume. Reports fatig
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