[SOLVED] Shadow Health Comprehensive SOAP Note Template

Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: ____TJ___ Age: _______ Gender: __F_____
SUBJECTIVE DATA:
Chief Complaint (CC): Tina Jones states, “I came in because I’m required to have a physical exam for the health insurance at my new job.”
History of Present Illness (HPI): Ms. Jones states she a recently been employed at Smith, Stevens, Stewart, Silver & Company. She needs a physical exam for a health insurance at her new job. She denies any acute concerns. She last visited her physician office four months ago and she received gynecological exams. She was diagnosed with polycystic ovarian syndrome, and she prescribed oral contraceptives. She denies any side effects from the oral contraceptives. She has been controlling her diabetes since her last visit. She states she checks her blood sugar at least once a day, take her prescribed metformin, exercise, and eat healthy. Overall, she is taking good of herself and following medical recommendations. She is excited to start her new job.
Medications: Metformin, 850 mg PO BID
Drospirenone and Ethinyl Estradiol PO QD
Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn
Acetaminophen 500 – 1000 mg PO prn
Ibuprofen 600 mg PO TID prn
Allergies: Denies food allergies
Denies latex allergies
Penicillin: rash
Allergic to cats and dusts (itchy and swollen eyes, runny nose, asthma symptoms).
Past Medical History (PMH): Patient was diagnosed with asthma 2 1/2 years and her inhaler helps relieve the asthma symptoms. Never intubated. She was diagnosed with type 2 diabetes at age 24, she started taking her metformin 5 months ago. She experienced some GI discomfort, but she has eating to help with the symptoms. She has been checking her blood sugar every morning and her average number is 90. She verbalizes she has been controlling her hypertension with diet and exercise. She denies ever been pregnant, last menstrual period was 2 weeks ago. Diagnosed with PCOS 4 months ago which she takes medication for it. She in a new relationship but with no sexual contact.
Past Surgical History (PSH): No surgeries
Sexual/Reproductive History: Diagnosed with PCOS 4 months ago, last menstrual period 2 weeks ago, never pregnant, no history of STD’S, AIDS and HIV four months ago.
Personal/Social History: Lives with mother and sister. Never married, no children. She starts her new job at Smith, Steven, Stewart & Company. She enjoys volunteering at her church. Family and friends are her strong social support, and they help relief her stress. She enjoys hanging out with friends and families. She denies use of tobacco and cocaine. She reports occasional use of alcohol when out with friends. She denies coffee intake. She drinks 1-2 soda’s a day. She currently eats healthy and exercise frequently. Her exercise includes walking, swimming, and yoga. Typical breakfast for Tina Jones is frozen fruit smoothie and unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread, dinner is roasted vegetables and protein, snack is carrot sticks or apple.
Health Maintenance: Last eye exams three months ago, last dental exam five months ago, last Pap smear 4 months ago.
Immunization History: Tetanus booster was received within a year, human papillomavirus received, all childhood vaccines and meningococcal vaccine received. Not received influenza vaccine.
Significant Family History:
Mother: age 50, high cholesterol, hypertension
Father: deceased in a car accident a year ago, age 58, type 2 diabetes, hypertension, high cholesterol
Brother: overweight, age 25
Sister: asthma, age 14
Maternal grandmother: died at age 73 of a stroke, history of high cholesterol and hypertension
Maternal grandfather: died at age 78 of a stroke, history of hypertension and high cholesterol.
Paternal grandmother: still living, age 82, hypertension
Paternal grandfather: died of colon cancer at age 65, history of type 2 diabetes
Paternal Uncle: alcoholism
Review of Systems:
General: Patient alert and oriented x4, good oral and personal hygiene. No recent illness, fever, chills, fatigue, and night sweats. Due to her recent diet and exercise change she lost 10 pounds.
HEENT:
Reports no headache, no history of head injuries. Reports no eye pain, itchy eyes, and redness. Wears eyeglasses. Denies ear problems, hard of hearing, ear pain and drainage. Reports no change in smell and sinus pain. Reports no problem with mouth, change in taste, dry mouth, sores. Reports no difficulty swallowing, missing teeth, sore throat, voice change and swollen nodes.
Respiratory:
Reports occasional shortness of breath and chest tightness. Denies no current difficulty breathing.
Cardiovascular/Peripheral Vascular:
Denies edema, chest pain, easy bruising, and palpitation
Gastrointestinal:
Denies nausea and vomiting, no abdominal pain, no diarrhea, no constipation, no food intolerance
Genitourinary:
Denies vaginal discharge or itching, polyuria, and hematuria
Musculoskeletal:
Denies muscle pain, joint pain, and muscle weakness
Neurological:
Denies light-headedness, dizziness, tingling, and loss of coordination or sensation.
Psychiatric:
Denies any mental health, denies any current anxiety and depression.
Skin/hair/nails:
She denies hair loss and nail changes. Reports moles. Reports improved acne after taking the oral contraceptives.
OBJECTIVE DATA:
Physical Exam:
Vital signs: B/P: 128/82, HR: 78, RR: 15, Pulse Ox: 98%, Temp: 37.2C Height: 170cm, Weight: 84kg, BMI: 29, Blood Glucose 100
General:
Patient alert and oriented x4, denies any current distress and discomfort.
HEENT:
Head and face appear symmetric. Bilateral eyes equal in size, round and brisk. No edema or redness noted. Conjunctiva pink and white sclera. No nystagmus. Mild retinopathic changes on the right. Left fundus with sharp disc, no hemorrhages. Snellen: 20/20 right, 20/20 left eye with corrective lenses. Positive light reflex. Whispered words bilaterally. Frontal and maxillary sinuses nontender to palpation. Midline spectrum. Oral and nasal mucosa moist and pink.
Neck: Smooth thyroid, no presence of goiter, neck symmetric and trachea midline.
Chest/Lungs: Chest appears symmetric, clear breath sounds and equal in all lung fields, no cough and wheeze. Absence of retractions, nasal flaring Spirometry reading: FVC: 1.78, FEV1 1.549
Heart/Peripheral Vascular:
Heart sounds regular, s1 s2 auscultated. No evidence of murmurs, gallops, or rubs. Equal bilateral carotid with no bruit, bilateral peripheral pulses equal. No peripheral edema. Capillary < 3 seconds.
Abdomen:
Abdomen symmetric, protuberant, no tenderness to palpation, no masses or scars noted. Bowel sounds normative in all quadrant x4. Absence of nausea, vomiting, constipation, or diarrhea.
Genital/Rectal:
No vaginal discharge, pain, and smell
Musculoskeletal: Gait steady, and even and ambulation appropriate for age. Full range of motion. No edema or masses
Neurological:
Alert and oriented x4, pupils round, equal, and reactive to light. Gag reflex intact and speech appropriate. Purposeful motor function, strength, and all sensation in all extremities. No headache, absence of facial droops, slurred speech, unilateral weakness, and numbness.
Skin:
Skin is warm and dry, scattered pustules on face and neck
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.