AHA SOAP Note Comprehensive Health AssessmentCASE ID# Tina Comprehensive AssessmentS.O.A.P. NoteSubj

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AHA SOAP Note Comprehensive Health Assessment

CASE ID# Tina Comprehensive Assessment

S.O.A.P. Note

Subjective

Objective

Assessment (diagnosis [primary and differential diagnosis])

Plan (treatment, education, and follow up plan)

Chief

Complaint

What brought you here today (e.g., headache) 

Pre-employment insurance physical exam

 

History of Present IllnessChronological order of events, state of health before the onset of CCOnsetMs. Jones came into the clinic today, stating that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She reported the need to get a pre-employment physical before she can start work. The patient denies any acute problems or concerns. Her last healthcare visit was four months ago. She received her annual gynecological exam and stated that the gynecologist diagnosed her with the polycystic ovarian syndrome and prescribed oral contraceptives at that visit. The patient reports that she is tolerating the new medication well. She has type two diabetes, which she is controlled with diet, exercise, and metformin. The patient reports she began taking metformin five months ago and is compliant with her regimen. She has no medication side effects at this time. She states that she has felt an improvement in her health as of late. Ms. Jones says that she is taking better care of her health and is excited to begin her new career.LocationDurationCharacterAggravating/associated factorsRelieving factorsTemporal factors – other things going onSeverityPast Medical HistoryAdult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications 

Asthma diagnosed at age 2 1/2. Albuterol inhaler for asthma exacerbations. Her last asthma exacerbation was three months ago. The last time she has been hospitalized for asthma was in high school. No intubations. Type 2 diabetes was diagnosed at age 24. She began metformin five months ago and initially had some gastrointestinal side effects which have since resolved. She monitors her blood sugar once daily in the morning, with average readings around 90. She has a history of hypertension, which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche at age 11. First sexual encounter at age 18. Never pregnant. The last menstrual period was two weeks ago. She was diagnosed with PCOS four months ago. For the past four months, her cycles have been regular (every four weeks) with moderate bleeding lasting five days and is taking the medication Yaz. She is in a new relationship with a male, but sexual contact has not yet been initiated. The patient stated that she plans to use condoms if and when sexual intercourse does occur. Tested negative for HIV/AIDS and STIs four months ago.

 

Current Home Meds:

 

• Fluticasone propionate, 110 mcg two puffs BID (last use: this morning)

• Metformin, 850 mg PO BID (last use: this morning)

• Drospirenone and Ethinyl estradiol PO QD (last use: this morning)

• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)

• Acetaminophen 500-1000 mg PO prn (headaches)

• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken six weeks ago)

 

Allergies:

 

• Penicillin: rash

• Denies food and latex allergies

• Allergic to cats and dust. When she is exposed to allergens, she states that she gets a runny nose, itchy and swollen eyes, and increased asthma symptoms.

 

 

Family HistoryInclude Parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical illnesses• Mother: age 50, hypertension, elevated cholesterol

• Father: deceased in a 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

 

Personal/Social HistoryEducation, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known 

The patient Currently lives with her mother and sister. She plans to move into an apartment within the next month. She is excited to begin her new career in a couple of weeks at Smith, Stevens, Stewart, Silver & company. The patient has a group of friends with well-developed relationships. Tina’s religion is Baptist. She has close ties with members of her congregation, which she views as family. Her support system helps her manage stress and anxiety. She denies ever using tobacco products. States that she used marijuana from age 15 to 21. She denies the use of methamphetamines, cocaine, heroin, or prescription drugs. She occasionally drinks when out with friends but usually just two to three times a month. She reports that she typically only has around three alcoholic beverages when out. The patient says that her diet is much improved. Breakfast usually consists of a fruit smoothie and unsweetened yogurt. Lunch is typically a sandwich on white bread or low-fat pita. For dinner, she typically has a portion of protein and vegetables. For snacks, she consumes carrot sticks and apples. She denies drinking coffee but usually drinks one to two diet sodas every day. She has also improved her activity level lately. She exercises four to five times per week by taking a walk, going for a swim, or participating in yoga.

 

Review of SystemsGeneral:The patient reports a recent weight loss of 10 pounds due to exercise and an improved diet. The patient denies current frequent illnesses, fevers, chills, night sweats, or other symptoms of concern.Hair, Skin, & Nails:No abnormalities reportedHead:Denies recurring headaches or other abnormalitiesNeck:No abnormalities reportedEyes:Denies recent changes in visionEars:No abnormalities reportedNose:No abnormalities reportedMouth & Throat:No abnormalities reportedCardiovascular:Denies recent sensation of palpitationsRespiratory:Reports improved breathing with maintenance asthma medicationBreasts:No abnormalities reportedGastrointestinal:

 

Genitourinary:

Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances.

 

Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge, or itching.

Musculoskeletal:Denies pain or other abnormalitiesPeripheral:No abnormalities reportedNeurological:Reports reduced level of stress and improved quality of lifePsychiatric:Denies current thoughts of self-harm, denies thoughts of harming others, denies feelings of depression and denies a sense of anxiousness  

 

 

Physical ExaminationVital signs:Blood pressure 128/82 mmHg, pulse rate 78 beats per minute, respirations 15 breaths per minute, temperature 99.0 degrees Fahrenheit, and O2 saturation 99% on room air, height 170cm, weight 84KgGeneral Appearance:The patient is a 28-year-old, well-developed, well-nourished female in no acute distress. She is alert and oriented, has good hygiene, and is dressed appropriately.HEENT:Normocephalic and atraumatic. Ears: There is no evidence of any external masses or lesions noted. Eyes: Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and anicteric. Nose: Nasal mucosa is pink and moist. The septum is midline. Mouth: Oral mucosa is pink and moist. Dentition is good.Neck:Supple. The trachea is midline. No evidence of thyroid enlargement. There is no jugular venous distention noted. There is no carotid bruits noted. There are no palpable masses.Lymph Nodes:There is no inguinal, axillary, supraclavicular or cervical lymphadenopathy or tenderness noted.Chest:Symmetric. Non-tender to palpation. Clear to auscultation bilaterally. There are no crackles, wheezes, or rhonchi noted. There is no crepitus on palpation. Resonant to percussion throughout. In-office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.Cardiac:Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, clicks, or rubs. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.Abdomen:Obese and benign. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Normoactive bowel sounds are present. No CVA tenderness or flank mass.Genitourinary:Not assessedSkin:Warm, dry, and well perfused. Good turgor. No lesions, nodules, ulcers or rashes are noted. No onychomycosis. Scattered pustules on the face and facial hair on the upper lip, acanthosis nigricans on the posterior neck.Musculoskeletal:Gait is coordinated and smooth. There is no clubbing, cyanosis, edema, or deformities. Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with a full range of motion. No pain with movement. TMJ has a full range of motion. No clicksNeurologic:No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through XII are grossly intact. Deep tendon reflexes are intact. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in the upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.Psychiatric:The patient is alert and oriented to person, place, and time. Appropriate mood and affect.AssessmentPrimary diagnosis:Physical Exam for Work Health InsuranceDifferential Diagnosis:Asthma, Diabetes Type 2, PCOSPlan1.Continue prescribed medications—albuterol for exacerbations and Flovent for daily maintenance.2.Continue to check sugars daily. Continue Metformin. Educate on the importance of continuing current improved diet and exercise habits to continue health improvement.3.Continue Yaz medication.

 

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