Shadow Health Comprehensive SOAP Note Template

Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example

Patient Initials: TJ                   Age:  28yrs                              Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): “I need a physical examination for health insurance at a new job opportunity.”

History of Present Illness (HPI): the patient denies any illnesses. She was diagnosed with diabetes and asthma five months ago.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Medications: The patient uses Metformin 850mg PO BID, Drospirenone/Ethinyl Estradiol Birth Control 1 tablet PO daily, and Flovent 110mcg/spray 2 puffs BID. She also used Proventil 90mcg/spray 2 puffs PRN to relieve wheezing and shortness of breath.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper  Example)

Allergies: The patient is allergic to cats, penicillin, and dust. Denies food allergies and latex.

Past Medical History (PMH): The patient was diagnosed with asthma at two years and experienced an asthmatic attack three months ago. She was also diagnosed with type II diabetes at 24 years, hypertension, and PCOS.

Past Surgical History (PSH): Denies previous surgeries.

Sexual/Reproductive History: The patient experienced menarche at age 11 and experienced her first sexual engagement at age 18. She is currently not engaged in sexual activity with her boyfriend, denies previous pregnancy, and recently (2 weeks ago) experienced menstrual flow. Four months ago, she was diagnosed with PCOS and experiences a regular and moderate menstrual cycle. She received a pap smear 4 months ago during a visit with a gynecologist.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Personal/Social History: The patient denies marriage and having children. She also denies using illicit drugs and substances while consuming alcohol 2-3 times a month. She also denies any mental health problems, including depression or anxiety. She used cannabis between the ages of 15-21 years. The patient prefers sunscreen, enjoys social support from friends and family, and resides with her mother.

Health Maintenance:  The patient undergoes regular dental, eye care, and pap smear. She engages in mild to moderate exercise activities like yoga, including getting adequate sleep, between 8-9 hours. She doesn’t have pets and consumes drink1-2 Diet Cokes per day instead of coffee.

Immunization History: The patient’s childhood vaccinations, meningococcal and tetanus booster, are up to date. She has not received Human Papilloma Virus and influenza vaccinations.

Significant Family History: The patient’s parents exhibited hypertension and high cholesterol, which runs through the family history. Her father died in a road accident and had type II diabetes. Her brother is overweight, while her sister is asthmatic. Her paternal grandfather died of colon cancer, while her paternal uncle is addicted to alcoholism.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Review of Systems:

General: The patient presents with decreased mental health problems like anxiety and depression. She does not contemplate suicide and receives adequate sleep.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

HEENT: The patient denies eye problems, headaches, and no ear pain. Denies runny nose, no dental problems, no sore throat, and lymph nodes are not swollen.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Respiratory: The patient denies shortness of breath, cough, or wheezing chest.

Cardiovascular/Peripheral Vascular: Denies problems with tachycardia, edema, or chest pains. She exhibits hypertension.

Gastrointestinal: Denies pain in the gastrointestinal tract or other issues like vomiting, constipation, and diarrhea.

Genitourinary: Patient denies hematuria, polyvuria, nocturia, or sexually transmitted infections.

Musculoskeletal: Denies muscle pain.

Neurological: Denies lightheadedness, dizziness, losing coordination or sensation, falls, or loss of balance.

Psychiatric: Denies mental health problems like depression, anxiety, suicidality, insomnia, and hypersomnia.

Skin/hair/nails: The patient reports acne improvement following oral contraceptive administration. Her skin quality has improved.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

OBJECTIVE DATA:

Physical Exam:

Vital signs:  The patient exhibits 128/82 BP, 99% O2, 78 BPM HR, 15 RR, and 97.3 Map/Cuff.

General: The patient denies pain. She does not present with fever, lethargy, chills, and recurring illnesses.

HEENT: The patient has equally distributed hair on the scalp and denies conjunctival discharge. She has equally sized pupils and no nystagmus or intact bilateral EOMs. She has mild retinopathic changes in the left eye and sharp disc margins on the left fundus. She has Snellen in both eyes and pearly gray tympanic membranes. She has a pink nasal mucosa and maxillary and frontal sinus. Her maxillary and frontal sinus is not touch-sensitive. Absence of cavities in the teeth with tonsils on both sides 2+. She also has smooth thyroid and lacks lymphadenopathy.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Neck:  the trachea is midline with no tumors on the neck.

Chest/Lungs: The patient’s chest is symmetrical with respiration, presents no chest problems, and has lung capacities comprising FVC 1.78 L and FEV1 1.549 L.

Heart/Peripheral Vascular: The patient has regular heart rates with equal bilateral pulses on both sides. Capillary refilling takes less than 3 seconds.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Abdomen: Denies abdominal pain, with normative bowel noises and a soft abdomen felt during palpitation.

Genital/Rectal: Denies genital problems.

Musculoskeletal: depicts no injuries or bruises, with full range achievement of 5+ strength in motion across the neck, elbows, ankles, fingers, hip, and shoulder.

Neurological: the patient presents with normal stereognosis, quick alternating motions, and graphesthesia. She is also aware of her environment and achieves normal cerebellar function tests.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Skin: The patient has smooth skin with no skin problems and presents with evenly distributed hair.

Diagnostic results: There are no diagnosis results since it is a normal examination.

ASSESSMENT: pre-employment

Diagnostic tests

Complete blood count: complete blood count should be conducted on the patient’s blood to determine the glucose levels and serum protein immunofixation (Lehmann et al., 2020). The procedure is necessary for determining the presence of distal symmetric polyneuropathy associated with the patient’s previous diabetic condition. Abnormal glucose levels will signify the presence of polyneuropathy.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

Comprehensive dilated eye exam: It can also be applied to test for diabetic retinopathy in the patient (Abidalkareem et al., 2020). The doctor drops a fluid in the eye to dilate the pupils and make it easy to identify eye problems like shortsightedness and longsightedness.(Tina Jones Shadow Health Comprehensive SOAP Note Template Nursing Paper Example)

References

Abidalkareem, A. J., Abd, M. A., Ibrahim, A. K., Zhuang, H., Altaher, A. S., & Ali, A. M. (2020, July). Diabetic retinopathy (DR) severity level classification using multimodel convolutional neural networks. In 2020 42nd Annual International Conference of the IEEE Engineering in Medicine & Biology Society (EMBC) (pp. 1404-1407). IEEE. https://doi.org/10.1109/EMBC44109.2020.9175606

Lehmann, H. C., Wunderlich, G., Fink, G. R., & Sommer, C. (2020). Diagnosis of peripheral neuropathy. Neurological research and practice, 2, 1-7. https://doi.org/10.1186/s42466-020-00064-2