Complete your Comprehensive (Head-to-Toe) Phy

Week 9

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

© 2021 Walden University, LLC Page 2 of 3

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-Ms. Jones -28-year-old -African American -single -religious preference -Education -Occupation: Smith, Stevens, Stewart, Silver & Company -Occupational history -woman -presents for a pre- employment physical. -She is the primary source of the history. -offers information freely and without contradiction. -Mrs. Jones Reliable historian

General Survey

Alert/oriented -seated upright -well-nourished -well-developed -dressed appropriately -good hygiene.

Reason for Visit

history of present illness

HPI: "pre-employment physical" prior to initiating employment." 

Patient Description of current overrall health: "feels healthy, is taking better care of herself than in the past"

Medications

+ Fluticasone propionate 110 mcg 2 puffs BID, Metformin, 850 mg PO BID, Drospirenone, ethinyl estradiol PO QD, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps) -using topical antifungals, anti-itch creams, steroid topical ointments, eye/ear/sublingual drops, Benadryl, herbs gingko/garlic/primrose.

Allergies

+Penicillin (Rash), dust/cats (runny nose, itchy swollen eyes) -Peanut, fish, gluten, lactose, onion, sulfa medication, opiate medications, latex allergies

.

Health Maitainance

+ Pap smear (4 months ago), eye exam (three months ago), dental exam (five months ago), PPD (negative, about 2 years ago), wears seatbelt, uses sunscreen. -Acupuncture, chiropractic care, changes in behavior/personality/mood, memory problems, difficulty learning.

Medical History

+ Asthma (diagnosed 24 years old), hypertension (resolved with diet/exercise), PCOS (Diagnosed 4 months ago), received childhood vaccinations, meningococcal vaccine (in college), hospitalized in high school for asthma exacerbations (resolved with use of inhaler without complication), tetanus booster (within last year), -Childhood chickenpox/rubella/polio, serious injuries MVA/broken bones/spinal cord injury, using a walker/cane/hearing aids, appendectomy, tonsillectomy, wisdom teeth removal, transfusion of blood/platelets/red blood cells, current flu vaccine.

Family History

• Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes• Brother (Michael, 25): overweight • Sister (Britney, 14): asthma• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol• Paternal grandmother: still living, age 82, hypertension• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes• Paternal uncle: alcoholism• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when "out with friends, 2-3 times per month," reports drinking no more than 3 drinks per episode. per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.

Mental Health History

Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.

Review of Systems- General

No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase.

HEENT

SUBJECTIVE 

Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.

OBJECTIVE 

Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Respiratory

SUBJECTIVE

Reports no current breathing problems. Reports occasional shortness of breath, wheezing, and chest tightness.

OBJECTIVE 

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

Cardiovascular

SUBJECTIVE

Reports no palpitations, tachycardia, easy bruising, (No Documentation Made) or edema.

OBJECTIVE

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Abdominal

SUBJECTIVE

Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.

OBJECTIVE

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

Musculoskeletal

SUBJECTIVE

Reports no muscle pain, joint pain, muscle weakness, or swelling.

OBJECTIVE

Bilateral upper and lower extremities without swelling, masses, or deformity and with full range of motion. No pain with movement.

Neurological

SUBJECTIVE

Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

OBJECTIVE

Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin, Hair, Nails

SUBJECTIVE

Reports improved acne due to oral contraceptives.

Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles

but no other hair or nail changes.

OBJECTIVE

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.

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