Shadow Health Comprehensive SOAP Note Assignment

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.

Ethnicity: African American Shadow Health Comprehensive SOAP Note Assignment

Chief complaint: “I want to have a physical examination for the health insurance at her new workplace.”

History of presenting complaint: Ms. Jones is a 28 years old African American female, recently employed at the Steven Stewart, and Silver company, and needs to obtain a pre-employment physical assessment. She denies any acute concerns.

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Current medication:

• metformin 850mg PO BD
• Drospirenone and Ethinyl estradiol PO QD are last to use in the morning
• Albuterol 90mcg/spray MDI 2puffs Q4H PRN last use was three months ago
• Acetaminophen 500-600mg PO PRN
• Ibuprofen 600mg PO TID PRN for menstrual cramps last taken 6 weeks ago
• Fluticasone propionate 110mcg 2puffs BID last use this morning
• Flovent 2puffs 88mcgs spray BID
• Proventil 2puffs PRN 90mcgs spray
• Yaz one tablet daily for PCOS

Allergies: the patient develops a rash when she takes penicillin. Develops runny nose, itchy and swollen eyes, and increased asthma symptoms when exposed to dust and cats. She treats the allergy by leaving the allergen, bathing, and using a rescue inhaler. She denies food and latex allergy. Shadow Health Comprehensive SOAP Note Assignment

Past medical history: the patient has asthma, diabetes mellitus, hypertension, and polycystic ovarian syndrome. She has had asthma since the age of two years and has been using her medication. She uses albuterol when she is around cats and reports hospitalization due to acute exacerbation but was never intubated. Her last asthmatic exacerbation was three months ago and resolved by using her inhaler. The patient has had type 2 diabetes mellitus since the age of 24 years. She has been taking her medication daily and monitors her blood sugar level, today’s reading was 90. She has a history of hypertension which is normalized by physical exercise and diet. She was diagnosed with polycystic ovarian syndrome four months ago.

Past surgical history: she denies a history of major and minor surgical procedures.

Sexual and reproductive history: the patient’s first sexual encounter was at the age of 18 years. She is heterosexual and plans to use a condom in her first encounter with her new partner. She tested negative for HIV/AIDS and STI. Her last menstrual period was three weeks ago. She had an irregular cycle until she initiated Yaz for four months and is now regular after every four weeks. She has never been pregnant. Shadow Health Comprehensive SOAP Note Assignment

Health maintenance history: the patient regularly goes for pap smear examination, eye check, dental check, and booster vaccines. Her last pap smear was four months ago and had normal findings. Her last eye examination was three months ago and her dental examination at 5months. She is up to date with her childhood immunization vaccines, her last tetanus was within the past year, and she is yet to get her influenza and human papilloma vaccine. She has smoke detectors in her house, uses a seat belt when in the car, uses sunscreen, and does not ride bikes. She has guns that belonged to her father, locked in her parent’s room.

Social history: Ms. Jones is single, has no child, and has lived independently since the age of 19 years. She is currently living with her mother and sister but plans to move to her apartment next month. She will begin her new job in two weeks at the smith, Steven, Stewart, and Silver company. She enjoys spending time with friends, dancing, volunteering in church, reading, and attending bible study. She is active in church and describes it as a strong unit and social support system. She states that the church and family cope with stress. She admits taking alcohol at least three times a month when she is out with her friends, at least three drinks per episode. She has a history of cannabis use from the age of 19 to 21 years. She denies the use of tobacco, cocaine, methamphetamines, and heroin. Her typical breakfast is a frozen fruit smoothie with unsweetened yogurt. Her lunch is vegetables with brown rice or a sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, and her snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pet Participates in mild to moderate exercise four to five times per we consisting of walking, yoga, or swimming.

Family history: she is the firstborn in her family. Her mother is 50 years living with hypertension and hypercholesterolemia. Her 25years old brother is obese. Her 14 years old sister is asthmatic. Her paternal uncle is an alcoholic and her 82 years old paternal grandmother has hypertension. Her father passed on at the age of 58 years in a road traffic accident. However, in his lifetime he battled hypercholesterolemia, hypertension, and type two diabetes mellitus. Her paternal grandfather passed on at 67 years due to colon cancer. Her maternal grandparents passed on due to hypertension, stroke, and hypercholesterolemia. Chronic illnesses in the family are colon cancer, hypertension, diabetes mellitus, stroke, hypercholesterolemia, asthma, and obesity. There is no positive history of sickle cell disease or mental health disorder. Shadow Health Comprehensive SOAP Note Assignment

Mental health history: she has reduced stress levels and improved coping mechanisms. However, she denies depression, anxiety, and suicidal ideation.

Review of system

General: the patient has no chills and rigors, weight loss, fever, night sweats, and fatigue.

HEENT: The patient denies headache, blurring of vision, eye pain, head trauma, jaw pain, sore throat, runny nose, and neck pain.

Cardiovascular: The patient denies chest pain, syncope, dyspnea, palpitations, orthopnea, and paroxysmal nocturnal dyspnea.

Respiratory system: the patient denies difficulties in breathing, coughing, sputum production, chest pain, and wheezing.

Gastrointestinal system: the patient denies vomiting, abdominal pain, nausea, diarrhea, reflux, heartburn, and constipation.

Genitourinary system: the patent denies vaginal discharge, vulval itchiness, lower abdominal pain, dysuria, polyuria, anuria, flank pain, and hematuria.

Musculoskeletal system: The patient denies pain in the muscles, back, neck or joints and swelling in upper or lower extremities.

Psychiatric: The patient denies insomnia, mood changes, anxiety, hallucinations, delirium, anxiety, and suicidal ideation.

Neurologic system: The patient denies headache, dizziness, changes in her gait and posture, resting tremors, body weakness, facial droop, tingling sensation, and numbness.

Skin/hair/nails: the patient reports reduced acne, facial and body hair distribution, and the neck stopped darkening due to contraceptives. She denies skin rash, breakout, brittle nails, and hair fall.

Objective Data

General: the patient seats upright on the examination table. she is calm, alert, and oriented. She has no pallor, jaundice, edema, cyanosis, dehydration, or lymphadenopathy. Shadow Health Comprehensive SOAP Note Assignment

Vitals: temperature 99.0F, HR 78 blood glucose 100, RR 15, BP 128/82, height 170cm, weight 84kgs, BMI 29.0, and Pulse OX 99%.

HEENT: the head is cephalic with no signs of trauma. Her eyes have bilateral equal hair distribution on the lashes and eyebrows. Her eyelids are without lesions and edema. The conjunctiva is pink with no lesions and the sclera is white. The pupils are equal and round reactive to light and accommodation bilaterally. The EOMs are intact bilaterally with no nystagmus. There are mild retinopathy changes on the right. The left fundus has sharp discs with margins. There are no hemorrhages. The Snellen is at 20/20 on the right eye, and 20/20 on the left eye with corrective lenses. The TMs are intact and pearly gray bilaterally with positive light reflex Whispered words are heard bilaterally. The Frontal and maxillary sinuses are nontender to palpation. Nasal mucosa moist and pink, septum midline. The Oral mucosa is moist without ulcerations or lesions, the uvula is midline on phonation. And the Gag reflex is intact. Dentition without evident caries or infection. She has Tonsils 2+ bilaterally and the Thyroid smooth without nodules, goiter, and lymphadenopathy.

Respiratory system: the anterior and posterior chest is normal with a symmetrical chest expansion. There are no areas of tenderness over the chest. There is a resonant percussion note. The lung fields are clear on auscultation. Resonant to percussion Spirometry FVC 3.91 L, FEV1/FVC ratio 80.56%

Cardiovascular system: the heart is at the mid-clavicle line, the 5th intercostal space. The heart sounds S1, and S2, are present. The heart rate has a regular rhythm and rate. However, there are no murmurs, heaves, thrills, gallops, or rubs. The carotids and peripheral pulses are bilaterally equal without bruit. The capillary refill is less than 3 seconds. There is no bilateral lower limb swelling.

Gastrointestinal system: the patient’s abdomen has a normal contour in the four quadrants. There is no organ enlargement. The liver span is 1cm below the costal margin. The spleen and kidneys are not palpable. There is a tympanic percussion note in all four quadrants. However, there is no fluid thrill and shifting dullness. The bowel sounds are normal-active in the four quadrants. Shadow Health Comprehensive SOAP Note Assignment

Musculoskeletal system: there is no deformity or swelling in the four limbs. The muscle strength is five out of five bilaterally in both lower and upper limbs. The muscle bulk, tone, and reflexes are intact. The limbs have a full range of motion. There is no pain during movement.

Neurological system: the patient has rapid alternating movements bilaterally. Tests for cerebella function are normal. She has a normal stereognosis. There is reduced monofilament in bilateral plantar surfaces.

Skin/hair/ nails: the patient has a normal scar, acne on her face, facial hair at the upper lip, and a visible old scar on the left shin. She has no nail abnormalities.

Diagnostic Tests: The appropriate tests for this patient are renal function tests to check fluid electrolyte balance because she has diabetes mellitus. Liver function test to rule out fatty liver disease because she is an overweight and positive history of alcohol intake (Jara, et al, 2019). Lipid profile to rule out hyperlipidemia because she is overweight.

Assessment

The patient has type two diabetes mellitus, polycystic ovarian syndrome, asthma, and hypertension. Her vitals are within the normal limits; random blood sugar at 100mg/dl and blood pressure at 128/82mmHg. The patient is overweight with a BMI of 29 and wears corrective lenses. She has a family history of stroke, hypertension, alcoholism, colon cancer, diabetes mellitus, colon cancer, and hypercholesterolemia.

Primary diagnosis: controlled diabetes mellitus in a patient known to have polycystic ovarian syndrome and asthma. Diabetes mellitus is a metabolic disease characterized by increased blood glucose levels due to insufficient insulin production (Oguntibeju, O. O. 2019). It presents with the blurring of vision, tingling sensation, blurring of vision, numbness, polyuria, polyphagia, and polydipsia. Causes are lifestyle habits such as alcoholism, sedentary living, family predisposition, and comorbidities. The patient has well-controlled blood sugar because she denies the symptoms. However, she has polycystic ovarian syndrome, which increases insulin resistance. Shadow Health Comprehensive SOAP Note Assignment

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 References

Jara, M., Dziodzio, T., Malinowski, M. et al. Prospective Assessment of Liver Function by an Enzymatic Liver Function Test to Estimate Short-Term Survival in Patients with Liver Cirrhosis. Dig Dis Sci 64, 576–584 (2019). https://doi.org/10.1007/s10620-018-5360-5

Oguntibeju, O. O. (2019). Type 2 diabetes mellitus, oxidative stress, and inflammation: examining the links. International journal of physiology, pathophysiology, and pharmacology, 11(3), 45. https://pubmed.ncbi.nlm.nih.gov/31333808  Shadow Health Comprehensive SOAP Note Assignment