Soap Note: Annual Wellness Checkup

Samples: Work on 2 Papers on Topics of Your Choice

Date of Encounter: 10/04/2024

Preceptor/Clinical Site: Shadow Health

Subjective

PATIENT INFORMATION

• ID: P.J.
• Age: 47 years old
• Gender: Female
• Race: Asian, American Chinese
• Date of Birth: August 11, 1977
• Marital Status: Married
• CC: “I am scheduled for my yearly medical examination and necessitate establishing care with a new healthcare provider."
• HPI:
  • The P.J.'s last annual assessment was in May 2021.
  • The results show that P.J. was within normal limits with no extraneous lab or physical tests.
  • Performs breast self-exams (BSE) mostly every day but sometimes forgets when in a hurry for work.
  • Last dental exam: June 2022
  • Last eye assessment was in December 2020
• Past Medical History:
  • HTN dx in August 2023
  • Asthma dx when she was still at the age of 5 years
• Past Surgeries/Hospitalizations:
  • Appendectomy performed in 2021.
  • Hospitalization in 2018 for left leg surgical repair following an accident.
  • Tubal ligation procedure in 2020 for contraception.
  • Hospitalization in 2022 due to COVID-19 infection.
• Medications:
  • Lisinopril, 10 mg once daily.
  • Denies use of herbal medicines
  • Albuterol inhaler to relieve her asthmatic exacerbations.
• Allergies:
  • Reports allergic to dog and cat fur. Exposure results in her experiencing wheezing and having challenges with breathing. P.J. reports that she is not allergic to any drug or food.
• Immunizations:
  • Tdap booster (06/2019)
  • Influenza vaccine (02/2020)
  • Covid booster shot (4/2022)
  • Complete childhood immunizations.
• Diet:
  • Avoids fast food, soda, sweet and salty food.
  • Regularly consumes fish, chick, and salads.
  • Drinks 6 glasses of water daily.
  • No energy drinks or coffee.
• Exercise/Sleep/Stress:
  • Perform power yoga and meditation daily.
  • No sleep problems.
• Substance Use/Smoking History:
  • Nonsmoker, no alcohol consumption.
  • No history of illicit drug use.
• Social/sexual history:
  • Married and shared a triplex with my spouse and two children.
  • Becomes professionally involved in engineering practice.
  • Engage exclusively in sexual activity with a single partner unprotected.
  • Identifies as a straight person.

ROS

• General: The patient looks well-nourished and appears in no acute distress. No significant weight fluctuations were mentioned. There is no fever, chills, or night sweats. No fatigue was also not reflected.
• Skin: P.J. reports no rashes, lesions, or itching. No history of skin cancer or significant sun exposure was mentioned. The frequency of sunscreen application may not be one of the critical parameters.
• HEENT. Head: There is no history of headache, migraine, or head trauma. Enables to prevent scalp sensitivity or hair loss. No vision changes are reported, and neither is the case with double vision. Eyes: It has been almost a year since the last eye checkup in August 2021. She denies a history of vision changes, such as blurred vision or eye pain. Reports lack of health records of eye surgeries or eye diseases. There had not been any need for corrective lenses. Ears, Nose, Throat: No episodes of ear infections and no signs of hearing loss or ringing sounds in ears. Histories of sinusitis, nasal congestion, or nosebleeds had never been mine. Denied complaints of a sore throat, hoarseness, or difficulty swallowing.
• Cardio: Has never experienced these symptoms. The patient denies any history of edema or cyanosis. There is no previously documented heart murmur or irregular heartbeat.
• Resp: Report a history of asthma that was diagnosed when I was 5 years old. Show her that she resorts to an albuterol inhaler for wheezing or shortness of breath. There is no history of chronic cough, sputum production, or hemoptysis. Indicate that he has never suffered pneumonia, bronchitis, or tuberculosis.
• GI: The patient does not have any complaints regarding the abdomen, such as pain, bloating, or changes in bowel habits. She says that she has not had nausea, vomiting, or diarrhea. Meanwhile, the patient reports an adverse GI bleeding history or black stools. The patient does not have any history of liver diseases or gallbladder disorders.
• GU: report the absence of urinary frequency, urgency, or dysuria by all means. Denies hematuria or any flank pain history. Had no earlier history of kidney stones or urinary tract infections. Denies history of sexual dysfunction or vaginal discharge reported.
• MSK: I was hospitalized in 2018 for left leg surgical intervention after an accident. The patient indicates no history of joint pain, stiffness, or swelling. Dismisses a history of back pain or muscle weakness. She reports no history of fractures, osteoporosis, or arthritis.
• Neuro: P.J. denies seizures, tremors, or weakness. The patient reports no numbness, tingling, or other changes in sensation. She has also reported no migraines or dizziness before.
• Psychiatric: She denies anxiety or mood fluctuations. She reports no previous episodes of suicidal ideation or self-harm are noted. She denies psychiatric hospitalizations or is on medications.
• Endocrine: P.J. refuses a medical history of diabetes or hypothyroidism. No excesses of thirst, urination, or appetite were reported. There are no adverse reactions to changes in hot or cold.
• Hematologic/Lymphatic: State that you do not have a history of bleeding disorders or easy bruising. The patient has no history of lymphadenopathy or swollen glands. Denis suffers from anemia or requires blood transfusions.
• Allergic/Immunologic: Allergic to cat and dog fur because it makes breathing hard and causes wheezing. Report multiple immunizations, e.g., influenza, Tdap, and COVID booster shots. Refuse to have a history of a severe allergic attack or anaphylaxis. Negate the occurrence of autoimmune disorders or immune deficiencies among ancestors.

Objective

• General: The patient looks relaxed and comfortable without noticeable aches or anxiety. She is placed in a chair that expresses her relaxed and complying facets. She is conscious and orientated. Her hair and nails are neatly arranged. The patient appears well-nourished. Her skin was warm and dry, but there were no signs of cyanosis, pallor, or jaundice. No edema on extremities is seen, and physical examination shows no visible scars or wounds.
• Vital Signs:
  • Temperature: 98.3 degrees Fahrenheit
  • Pulse: 102 bpm
  • Pulse Oximeter: 96% on room air
  • Respirations: 23 breaths per minute
  • Pain Score: 0/10
  • Weight: 185 lbs
  • Height: 5'8"
  • BMI: 28.1 BMI (Overweight)
  • Last Menstrual Period (LMP): More than three years ago (Post-menopause).
• Head and Neck: Normocephalic and atraumatic. No palpable lymphadenopathy was detected in the cervical region. The thyroid gland is not palpable, so no enlargement or nodules are also felt.
• Eyes: PERRLA. Extraocular movements are regular. No scleral jaundice or pallor demarcates the conjunctiva. Fundoscopic exam deferred.
• Ears, Nose, and Throat: The tympanic membranes are intact and pearly gray bilaterally. The nasal mucosa is pink and moist, with no bleeding or discharge. The oropharynx is clear, the tonsils are not enlarged, and the uvula is midline. The dentition is in good repair, with no apparent cavities or gum disease.
• Chest and Lungs: Symmetric chest expansion. Respiratory effort is normal, with no use of accessory muscles. Percussion reveals resonance bilaterally. Bronchial breath sounds are heard over the trachea, and vesicular breath sounds are heard over lung fields. No wheezes, rales, or rhonchi are auscultated.
• Cardiovascular: Apical impulse palpable at the fifth intercostal space midclavicular line. No thrills or heaves were palpated. Peripheral pulses present and equal bilaterally (radial, brachial, femoral).
• Abdomen: Abdomen soft, non-tender, and non-distended. Bowel sounds are present in all four quadrants. No masses or organomegaly is palpable. No rebound tenderness or guarding was noted.
• Musculoskeletal: Normal range of motion in all major joints without pain or crepitus. Muscle strength is 5/5 in the upper and lower extremities bilaterally. No deformities or swelling were observed in the extremities.
• Neurological: Cranial nerves II-XII are intact. Normal function for sensation to light touch, proprioception, and vibration. No focal deficits in motor strength and function are noted.
• Skin: No lesions, ulcers, or rash were observed. Skin turgor is normal, and no tenting can be observed. There is no evidence of clubbing, cyanosis, or peripheral edema.

Plan

Pharmacological Intervention

• The patient must strictly follow the prescribed Lisinopril dose and use the Albuterol inhaler as directed by the doctor. Lisinopril is essential in decreasing blood pressure (Sonn et al., 2019). Consistent monitoring through periodic audits will assess the function of these medicines and pay attention to their side effects.

Non-pharmacological Intervention

• P.J. needs to change most of her life habits radically, like eating a low-salt diet and getting more physical exercise. Through yoga and meditation, she can overcome stress management and understand her mental health concerns.

Patient Education

• Sensitizing the patient with cat and dog fur about the necessity of avoiding the allergens related to her health is vital (Bjermer et al., 2019). In the event that total evasion is not possible, antihistamine may be employed to alleviate reactions.

Regular Check-ups

• Regular health checks must be part and parcel of the regime of hypertension/asthmatic patient monitoring and identifying any other clinical problems at the earliest stage. This implies a regular health checkup (including an eye exam and dental scan) to accommodate health needs and monitor the situation appropriately.

Breast Self-Exams

• The patient must engage in regular monthly breast self-detection and immediately bring any instance of irregularities or changes as she discovers them to her healthcare provider. Timely detection of the disease is considered the most crucial element of the entire issue and can significantly facilitate the management of the condition.