Shadow Health Comprehensive SOAP Note Template Discussion

Patient Initials: _______                     Age: _______                         Gender: _______

 SUBJECTIVE DATA:

 Chief Complaint (CC): “I came here since my new job’s health insurance requires that I have a current physical examination.”

 History of Present Illness (HPI): Ms. Jones states that she has a new position at a new firm and must undergo a pre-employment medical examination before beginning work. She currently denies that she has any significant concerns. Her most recent medical visit was for an annual gynecological exam four months ago. Her doctor diagnosed her with polycystic ovarian syndrome and prescribed an oral contraceptive, which she tolerates well.  She has type 2 diabetes, which she controls with a mix of diet, the drug metformin, and exercise. Which she has been taking for five months. She is not having any side effects from her medicine at this time. She claims to be in excellent health, that she is taking better care of herself than in the past, and that she is looking forward to starting her new work Shadow Health Comprehensive SOAP Note Template Discussion.

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Medications:

Acetaminophen 500-1000 mg PO prn

Fluticasone propionate, 110 mcg 2 puffs BID

Ibuprofen 600 mg PO TID prn

Albuterol 90 mcg/spray MDI 2 puffs Q4H prn

Metformin, 850 mg PO BID

Drospirenone and ethinyl estradiol PO QD

Allergies:

  • Allergic to cats and dust.
  • Denies food and latex allergies
  • Penicillin: rash

Past Medical History (PMH): Ms. Jones was diagnosed with asthma when she was two and a half years old. She uses her albuterol inhaler when she’s around cats. Her most recent asthma episode, which she was able to cure with her inhaler, happened three months ago. Last she was admitted to the hospital for asthma was when she was in high school. Never intubated. She was diagnosed with type 2 diabetes at the age of 24. She began taking metformin 5 months ago and had some gastrointestinal side effects, which have now disappeared Shadow Health Comprehensive SOAP Note Template Discussion.

Her blood sugar is examined once a day in the morning and is usually around 90. She has a history of hypertension, which she was able to manage with proper nutrition and exercise. No surgeries.

Past Surgical History (PSH): None

Sexual/Reproductive History: Menarche at the age 11. She had her first sexual encounter with a male at the age of 18 and declared herself straight. She has never been pregnant before. It has been two weeks since she has had a period. Four months ago was diagnosed with PCOS. Since taking Yaz, cycles have been constant for the previous four months, with minimal bleeding taking up to five days. She tested negative for STIs and HIV/AIDS four months ago.

Personal/Social History: Ms. Jones is a single woman who has never married or had children. She has been living freely since she was 19 years old. She currently lives in a single-family home with her mother and sister, but she will be moving into her own apartment in a month. She will begin her new job in two weeks. She enjoys reading, assisting in her church’s Bible study, and dancing with her friends. Tina is very involved in her religion and has a large family and social support system. Her family and religion, she adds, support her in coping with stress. She is a non-tobacco user. Use of cannabis between the ages of 15 and 21. There are no reports of methamphetamines, heroin, or cocaine use. Drinks alcohol on occasion. Denies drinking coffee, she admits to taking 1-2 diet sodas every day. There hasn’t been current overseas travel Shadow Health Comprehensive SOAP Note Template Discussion.

Exercises that are mild to moderate in intensity.

Health Maintenance: She got a Pap smear four months ago. Her last eye test was three months ago. It had been five months since she had a dental checkup. Tested negative for PPD two years ago.

Immunizations: A tetanus booster was given lately, however influenza and human papillomavirus vaccinations were not provided this year. She claims to have gotten the meningococcal vaccine for college and to be up to date on her child vaccines. Has smoke detectors installed in the home, wears a seatbelt while driving, and does not ride a bicycle. Uses sunscreen on a regular basis. Guns that previously belonged to her are now in the house, stashed up in her parents’ room.

Immunization History:  In the previous year, a tetanus booster was provided, no influenza or human papillomavirus vaccines were given. She claims to be up to date on child vaccines and to have had the meningococcal vaccine while in college.

Significant Family History: Father: died at 58 in a car accident, hypertension diabetes, high cholesterol

Mother: high cholesterol hypertension,

Sister: Asthmatic

Brother: Obese

Paternal grandmother: still living, age 82, hypertension

Paternal grandfather: Died of colon cancer, history of diabetes

Maternal grandfather: Died of stroke, history of hypertension

Maternal grandmother: died of stroke Shadow Health Comprehensive SOAP Note Template Discussion

Review of Systems:

General: No recent or recurring illnesses, tiredness, night sweats, chills, or fevers. There have not been any recent or recurring infections. A recent ten-pound weight reduction owing to a change in diet and increased physical activity is noted.

            HEENT: There are no current headaches, and no history of head injuries or acute visual anomalies reported. There have been no reports of eye irritation, itching, redness, or dryness. The patient wears corrective glasses. Her last visit to the optometrist had been three months ago.

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There have been no reports of ear problems in general, nor has there been any change in hearing. There has been no ear pain or discharge recorded. So far, no changes in scent, sneezing, rhinorrhea, epistasis, sinus pain or pressure, or have been recorded. The patient has reported no general oral problems, changes in taste, dry mouth, pain, sores, or concerns with the jaw or tongue. There are no present dental problems, and the last dental visit was five months ago. There have been no reports of difficulty swallowing, voice changes, swollen lymph nodes or sore throats Shadow Health Comprehensive SOAP Note Template Discussion.

Respiratory: Denies cough, wheezing dyspnea, shortness of breath or, chest pain.

            Cardiovascular/Peripheral Vascular: Denies edema, palpitations easy bruising, or tachycardia.

            Gastrointestinal: Denies food intolerances. Denies abdominal pain, nausea, vomiting, or constipation, diarrhea.

            Genitourinary: Denies hematuria, polyuria, dysuria, pain, vaginal itching, or discharge, nocturia

            Musculoskeletal: Denies muscle weakness, muscle pain, or swelling joint pain

            Neurological: Denies seizures, sense of imbalance. Light-headedness, loss of sensation or coordination, tingling, and dizziness,

            Psychiatric: Denies anxiety, depression, and other mental illnesses.

            Skin/hair/nails: Oral contraceptives, she believes, have reduced her acne. Her facial and body hair has improved, and the discoloration of her neck skin has ceased. She has a few of moles but no other hair or nail changes Shadow Health Comprehensive SOAP Note Template Discussion.

OBJECTIVE DATA:

 

Physical Exam:

Vital signs: Height: 170 cm

  • Blood Glucose: 100
  • Weight: 84 kg
  • BP: 128 / 82
  • Temperature: 99.0
  • RR: 15
  • HR: 78
  • BMI: 29.0
  • Pulse Ox: 99%

General:

HEENT: Head is nomocephalic.

Frontal and maxillary sinuses nontender to palpation

Gag reflex intact. Moist oral mucosa.

Moist nasal mucosa, mild retinopathic changes on the left; TMs intact;

Thyroid smooth without nodules, no goiter

Tonsils 2+ bilaterally

 

Chest/Lungs: Chest is symmetric with respiration, clear to auscultation bilateral without wheeze or cough. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Resonant to percussion throughout.

Heart/Peripheral Vascular: Heart rate is regular, S1, S2, without gallops rubs, or murmurs. PMI at the midclavicular line, 5th intercostal space, no heaves thrills, or lifts. No peripheral edema, bilateral peripheral pulses equal bilaterally, capillary refill less than seconds. Bilateral carotids equal bilaterally without bruit Shadow Health Comprehensive SOAP Note Template Discussion.

Abdomen: No guarding or tenderness to palpation. Abdomen symmetric, protuberant, no visible scars, lesions, masses, or coarse hair from pubis to umbilicus. No organomegaly. No CVA tenderness. Bowel sounds are normoactive in all four quadrants.

Musculoskeletal: No pain with movement. Strength 5/5 bilateral upper and lower extremities with full range of motion. No swelling, deformity, or masses.

Neurological: Normal rapid alternating movements, graphesthesia, and stereognosis bilaterally. Normal cerebellar function. DTRs and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin: Facial hair on upper lip. Acanthos nigricans on posterior neck. Scattered pustules on face.

 ASSESSMENT:

 PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses Shadow Health Comprehensive SOAP Note Template Discussion