Shadow Health Comprehensive SOAP Note Template

Shadow Health Comprehensive SOAP Note Template

Patient Initials: ___TJ____                 Age: __28_____                                 Gender: _F______

 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 is a 28-year old African American female who presents to the clinic and claims that she has obtained a new position with a new organization, but in order to begin her new career, she is required to first successfully complete a pre-employment medical examination. She asserts that she does not have any significant worries at this juncture. Four months ago, she went in for her yearly gynecological exam, which was her most recent scheduled medical visit. Her physician diagnosed her with polycystic ovarian syndrome after examining her, and he suggested that she use an oral contraceptive that she didn’t have any adverse reactions to. She is able to keep her type 2 diabetes under control by paying attention to what she eats, taking the diabetic medicine metformin, and being active. She has been taking this medicine consistently throughout the course of the last half year. At this point in time, she is not exhibiting any unfavorable reactions to the medicine she is taking. According to her, she is in excellent health, has improved her hygiene habits, and is eager to begin her new job in the near future. The attending physician gave her a prescription for metformin and suggested that she make use of a daily inhaler during her most recent consultation for a comprehensive medical checkup, which took place around five months ago Shadow Health Comprehensive SOAP Note Template.

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Medications:

Albuterol 90 mcg/spray MDI 2 puffs Q4H prn

Drospirenone and ethinyl estradiol PO QD

Metformin, 850 mg PO BID

Ibuprofen 600 mg PO TID prn

Fluticasone propionate, 110 mcg 2 puffs BID

Acetaminophen 500-1000 mg PO prn

Allergies:

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

Past Medical History (PMH): At age 2 and a half, She was given the diagnosis of asthma. Her most recent episode of asthma flare-up occurred three months ago and was successfully treated with an inhaler. At the age of 24, She was given a diagnosis of diabetes. Since five months ago, she has been using metformin. PCOS was diagnosed around four months ago, and she is now on Yaz. Negative results on all STI tests taken four months ago.

Past Surgical History (PSH): Denies surgical history

Sexual/Reproductive History: 11 years old is the age of her menarche.d At the age of 18, she had her first sexual experience and she identifies as heterosexual. She has not before carried a pregnancy. It had been a fortnight since the last time she got her menses. She was given a diagnosis of PCOS around four months ago. Since beginning treatment with Yaz, menstrual cycles have been regular for the last four months, with just minor bleeding lasting for up to five days at a time. Four months ago, she had negative results for sexually transmitted infections and HIV/AIDS.

Personal/Social History: No children. Never married. Currently has a boyfriend Consumes alcohol on occasion but asserts that she does not smoke or use any illegal substances. Participant in church activities. She says she does not drink coffee, but she does admit to consuming one to two diet sodas per day.

Health Maintenance: Eats healthy and conducts physical exercises regularly. Pap smear four months ago. Eye check up 3 months ago.

Immunization History: Childhood immunizations are current. Current tetanus immunization. Influenza vaccine not current

Significant Family History: Shadow Health Comprehensive SOAP Note Template

Mother: high cholesterol hypertension,

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

Brother: overweight

Sister: Asthma

Paternal grandfather: Died of colon cancer, history of diabetes

Paternal grandmother: still living, age 82, hypertension

Maternal grandmother: died of stroke

Maternal grandfather: Died of stroke, history of hypertension

Review of Systems:

General: There is no history of sickness, either recent or recurrent, as well as no fatigue, night sweats, chills, or fevers. There have not been any new infections or recurrences in recent times. She has observed that a recent weight loss of ten pounds occurred as a result of a modification in diet and an increase in the amount of physical activity.

HEENT: Denies headache, history of head injury. Denies visual changes, eye pain, itchy eyes, dry eyes or redness. Wears corrective lenses. Denies ear problems, ear pain or hearing changes. Denies sneezing, epistasis, sinus pain, rhinorrhea, or change in sense of smell. Denies mouth pain or dental issues. Denies voice changes, difficulty swallowing, sore throat. Denies swollen lymph nodes.

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Respiratory: Denies cough, wheezing, dyspnea, shortness of breath, or phlegm

Cardiovascular/Peripheral Vascular: Denies chest pain, chest pressure, swelling, palpitations, or irregular heartbeat.

Gastrointestinal: Denies diarrhea, constipation, abdominal pain, nausea, or vomiting. Denies food intolerances or changes in bowel movements.

Genitourinary: Denies polyuria, ain on urination, hesitancy, vaginal itching, or discharge.

Musculoskeletal: Denies back pain, muscle weakness, muscle pain, swelling, joint pain or stiffness.

Neurological: Denies vertigo, seizures, sense of disequilibrium. Denies dizziness, light-headedness, numbness, or tingling, loss of sensation or coordination.

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

Skin/hair/nails: She feels that using oral contraceptives has helped minimize her acne. Her face and body hair has become healthier, and the discoloration that had been present on the skin of her neck has disappeared. She has a few moles, but other than that, her hair and nails are unaltered.

OBJECTIVE DATA:

 

Physical Exam:

Vital signs:

• Blood Glucose: 100
• Temperature: 99.0
• O2 Sat: 99%
• Weight: 84 kg
• Height: 170 cm
• BP: 128 / 82
• RR: 15
• HR: 78
• BMI: 29.0

General:

HEENT: Head is nomocephalic and atraumatic. Pink conjunctiva, white sclera.

Frontal and maxillary sinuses nontender to palpation. TMS pearly grey and intact.

Moist oral mucosa. Gag reflex intact. Moist nasal mucosa, mild retinopathic changes on the left; TMs intact;

Tonsils 2+ bilaterally. Thyroid smooth, no nodules or goiter

Chest/Lungs: Chest is symmetric with respiration, lungs clear to auscultation, no cough or wheeze. Resonant to percussion throughout.  In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

.Heart/Peripheral Vascular: RRR, S1, S2, no gallops, rubs, or murmurs. Bilateral carotids equal bilaterally without bruit. Capillary refill less than 3 seconds. No peripheral edema, bilateral peripheral pulses equal bilaterall.  PMI at the midclavicular line, 5th intercostal space, no heaves thrills, or lifts.

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

Musculoskeletal:. Strength 5/5 in bilateral upper and lower extremities. Full range of motion noted. No masses, deformity, or edema.

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

Skin: Acanthos nigricans noted on posterior neck. Facial hair on upper lip. Scattered pustules on face. Shadow Health Comprehensive SOAP Note Template

 

ASSESSMENT:

Encounter for pre-employment examination

Type 2 Diabetes Mellitus

PCOS

Hypertension

Asthma

 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

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Chapter 7, “Mental Status” This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms. ·Chapter 23, “Neurologic System” The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings. Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Chapter 4, “Affective Changes” This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis. Chapter 9, “Confusion in Older Adults” This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination. Chapter 13, “Dizziness” Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination. Chapter 19, “Headache” The focus of this chapter is the identification of the causes of headaches. Shadow Health Comprehensive SOAP Note Template

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The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam. Chapter 31, “Sleep Problems” In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis. Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5) Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment. Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center. Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Kim, H., Lee, S., Ku, B. D., Ham, S. G., & Park, W. (2019). Associated factors for cognitive impairment in the rural highly elderly. Brain and Behavior, 9(5), e01203. https://doi.org/10.1002/brb3.1203 Lee, K., Puga, F., Pickering, C. E., Masoud, S. S., & White, C. L. (2019). Transitioning into the caregiver role following a diagnosis of Alzheimer’s disease or related dementia: A scoping review. International Journal of Nursing Studies, 96, 119–131. https://doi.org/10.1016/j.ijnurstu.2019.02.007 O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy Shadow Health Comprehensive SOAP Note Template