Discussion Topic: Soap Note 1 ‘ADULT’ ?Wellness check up Requirements – The discussion must address the topic – Rationale must be provided – Use at least 600 words, co

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Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up

PATIENT INFORMATION

Name S.N.

Age: 55 yrs

Gender at Birth: Male

Gender Identity: Male

Source: Patient

Allergies: Denies food, environmental, or drug allergy

Current Medications: Denies use of medications. Takes no herbal medicines or supplement

medications.

PMH: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN,

psychiatric diseases, asthma, or diabetes.

Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on

5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was

unable to recall the exact dates.

Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021

Surgical History: No history of recent or previous surgeries.

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Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes.

Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a

history of BPH and HTN.

Social History: He is a small-scale farmer. Married to one wife.Has three children. He neither

smokes nor drinks.

Sexual Orientation: He has one wife, and he is heterosexual

Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He

takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not

drink sweetened drinks or coffee.

Subjective Data:

Chief Complaint: "I am feeling great, but I am here for my annual check-up."

Symptom analysis/HPI: The patient's last annual check-up was in May 2021. The patient

reports the absence of any abnormal laboratory or physical findings during that check-up. His

previous eye examination was on October 2021. His last dental review was in November 2021.

Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar

Screening were done in March 2021. Lip profile tests were done in January 2017. There were no

other current concerns or complaints by the patient.

Review of Systems (ROS

CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever

RESPIRATORY: No dyspnea, wheezing, chest pains, or cough

GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea

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NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion

HEENT: H: no dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry

vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching,

or discharge o Throat: no sore throat, edema, or voice changes

CARDIOVASCULAR: no chest pains, palpitations,dizzness or edema

GENITOURINARY: no dysuria, discharge, urinary urgency, or hematuria

MUSCULOSKELETAL: no muscle pains, joint swelling, joint pain, or muscle spasms

SKIN: no hives, skin rashes, or hyperpigmentation

Objective Data:

VITAL SIGNS: BP-110/90 mmHg, RR 19, Pulse rate 70b/min . SPo2 is 100%. Height-180cm,

Weight-63kg, computed BMI-22.5

GENERAL APPEARANCE: A white male, seated, alert and well-nourished, with no signs of

respiratory distress. There is no pallor, jaundice, cyanosis, dehydration, edema, or

lymphadenopathy.

NEUROLOGICAL: Normal speechA& O x3, typical gait, no tremors, normal speech, no

cerebellar S/S, or motor-sensory loss.

RESPIRATORY: Chest wall is symmetrical, rises following respiration, no visible masses or

scars, no tenderness, percussion note is tympanic, bilateral entry of air, breath sounds were

normal following auscultation.

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CARDIOVASCULAR: Normoactive precordium, palpable apical pulse mid-clavicular line at

the 5th ICS, regular H.R., no thrills, no heaves, On auscultation, there were no murmurs, and S1

and S2 were heard.

GASTROINTESTINAL: Flat abdomen, umbilicus everted, moving with respiration, no

masses, no tenderness or organomegaly; warm. Normoactive bowel sounds were heard.

INTEGUMENTARY: Dark, warm, and dry. No rashes, abrasions, lesions, or hives

HEENT: H: Normocephalic, no scars, masses, or bruises. E: Pupils are equal, round, and

reactive to light, with no discharges. E: no ear discharges or impacted wax N: Symmetrical,

patent nasal nares, no discharge or bleeding.

Neck: No distended veins or lymphadenopathy and supple

MUSCULOSKELETAL: No abnormalities, normal gait, normal reflexes, no deformities, and

normal ROM.

ASSESSMENT:

55-year-old S.N. came to our clinical for his annual check-up. There are no current complaints.

His last yearly check-up showed no abnormal findings. His past check-ups were eye exam,

dental exam, Prostate screening, colonoscopy, lipid profile check-up, and B.P. and B.S.

screenings mother has hypertension and diabetes. His maternal grandfather had a history of

hypertension and BPH. On general and physical examination, there were no abnormal findings

noted.

Main Diagnosis

-1. ICD Z00.00- Annual checkup with no abnormal findings.

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CDC recommends the performance of routine check-ups annually and lab testing to aid in

identifying any health disorders to facilitate early medications and management (CDC,2020).

The patient requires his annual check-up this year.

Preventative Service Task Recommended Screenings:

2. PSA screening-ICD 10 –CM Z12.5. This is essential for screening for malignant cancers of the

prostate.PSA screening is vital in all men above 50 years because of the risk of developing

prostate cancer (Catalona,2018). The patient is at risk of prostate cancer or BPH because of his

old age and a positive family history of BPH.

3. Update for immunization-ICD-10-CM-Z23-which is the encounter for immunization.CDC

recommends that every adult be given a single dose of Tdap and then Td or a booster for Tdap

after ten years (Hibberd,2020). Mr. SN has his immunization updated apart from Tdap.

4. Colonoscopy- ICD 10 -CM Z12.11, which is for encounter for screening for the malignant

cancers of the colon. Colonoscopy is a requirement for individuals above 50 years as it will help

in the early diagnosis of benign or malignant lesions in the rectum or the colon (Saito et

al.,2021).

5. Blood Pressure screening-ICD 10-CM Z01.30 is the encounter for assessing blood pressure

with no abnormal findings. B.P. should be regularly checked in adults above 50 years (Carey et

al.,2018). This patient is at risk of developing HTN because of the positive family of HTN.

6. Blood Sugar Screening- ICD 10-CM R73.09, the code for the HBa1c blood test. This will help

rule out diabetes mellitus and is a requirement for people above 45 years. The patient is at risk of

developing D.M. because of the positive family history.

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7. Lipid profile Check-ICD 10-CM Z13.220 in assessing lipid metabolism errors, the cholesterol

and lipid-protein levels in the blood (Vijan & Elmore, 2020). CDC recommends that adults

above 20 years have cholesterol check-ups every five years (CDC,2020).

PLAN:

Investigations

-CBC- To investigate the white blood cell differentials, RBC, and platelet

-Urinalysis-To assess any abnormalities in the urine

-UECs-To assess the electrolytes

-Lipid tests-Helps in the assessment of the levels of LDL, cholesterol, T.G.s, and HDL

-ECG and ECHO- To assess the electrical activity of the heart and any heart disorders

-Renal function tests-To assess any kidney problems

-TSH-For assessment of any thyroid disorders.

Education

1. Continue monitoring any health changes, and for any threatening health conditions, call,911

2. Have a physical exercise plan at least exercise four times a week

3. Continue with his diet and maximize taking a balanced diet, more fruits and vegetables, and

drinking seven glasses of water daily.

Follow-ups

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Advise the patient to return to the hospital after one week to assess his laboratory

findings. He can book an appointment or make a call in case of any health issues. His next

annual check-up is to be scheduled for January 2023.

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References

Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee*.

(2018). Prevention, detection, evaluation, and management of high blood pressure in

adults: synopsis of the 2017 American College of Cardiology/American Heart

Association Hypertension Guideline. Annals of internal medicine, 168(5), 351-358.

https://doi.org/10.7326/M17-3203

Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214.

https://doi.org/10.1016/j.mcna.2017.11.001

Diphtheria, tetanus, and pertussis vaccine recommendations. (2020). Centers for Disease Control

and Prevention. Retrieved January 31, 2021, from

https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/recommendations.html

Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved

February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-

vaccination- in-adults

Saito, Y., Oka, S., Kawamura, T., Shimoda, R., Sekiguchi, M., Tamai, N., … & Inoue, H. (2021).

Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 486-

519. https://doi.org/10.1111/den.13972

Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate. Waltham,

MA: UpToDate. https://www.medilib.ir/uptodate/show/4553