Notesale: Turn your study into money

Document Preview

Extracts from the notes are below, to see the PDF you'll receive please use the links above

---

Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: __TJ_____

Age: __28_____

Gender: __F__

SUBJECTIVE DATA:
Chief Complaint (CC):
“I came in because I’m required to have a recent physical exam for the health
insurance at my new job
...
Tina Jones is a 28-year-old African American female that presents to the
office today with reports of needing a physical examination for the health
insurance she will be getting with her new job
...

Reports that her asthma and diabetes have been under control and has not had
any recent issues
...
She was
diagnosed with PCOS at her last gynecologist visit and prescribed birth control
...

Medications:


Yaz: PO one tablet daily
...


Allergies:


PCN- rash and hives



Cats- itchy, watery eyes, runny nose



Dust-itchy, watery eyes, runny nose
...




Diabetes- diagnosed at age 24
...
Resolved after treatment with Famotidine
...
Resolved with BC



HTN- resolved with changes in diet and exercise

Past Surgical History (PSH):


Denies any surgical history

Sexual/Reproductive History:


G0P0, LMP 2 weeks ago, regular menstrual cycles since she started birth
control around 4 months ago
...
She reports using
protection during sexual intercourse
...
Jones is currently living with her mother and sister
...
She has obtained a B
...
degree and will soon
begin a new job with Smith, Stevens, Stewart, Silver & Company
...
She reports
consuming alcohol approximately 2-3 times/month when she is out
with friends
...

Caffeine consumption with consumption of 1-2 cand of diet soda
per day
...
She enjoys being active in her church and family
...
was prescribed glasses
...




Tetanus booster x 1 year ago



Influenza vaccine- 5-6 years ago



HPV- not received

Significant Family History:

© 2021 Walden University, LLC

Page 3 of 9



Mother: age 50, HTN, High cholesterol



Father: HTN, DM, High Cholesterol; died at age 58 from car accident



Sister: 15, asthma



Brother: 27, overweight



Maternal Grandmother: HTN, High cholesterol; died at age 78 from CVA



Maternal Grandfather: HTN, High cholesterol; died at age 80 from MI
...
Reports
recent weight loss but reports weight loss is due to dietary changes and
increased exercises
...
Reports blurry vision
prior to wearing eyeglasses
...
patient prescribed eyeglasses at this visit
...
Denies dental appliances or dental
pain
...
Denies throat pain, difficulty
chewing, or difficulty swallowing
...

Cardiovascular/Peripheral Vascular:

© 2021 Walden University, LLC

Page 4 of 9

Denies chest pain, palpitations or edema
...

Genitourinary:
Reports urinating less frequently
...

Denies abnormal vaginal bleeding or vaginal discharge
...
Denies
gait disturbances
...
Denies loss
of sensation, numbness, or tingling
...

Denies any depression, anxiety, or suicidal thoughts
...

OBJECTIVE DATA:
Physical Exam
Vital signs:


BP: 128/82



HR: 78

© 2021 Walden University, LLC

Page 5 of 9



RR: 15



O2: 99 % on room air



Temp: 37
...
9 F)



random glucose: 100



Height: 5'7"



Weight: 90 KG



BMI: 31
...
She is alert and oriented without any acute distress
...
Throughout the interview, she is able to
maintain eye contact with the provider
...

grommet and well nourished
...


HEENT:
Head is normocephalic
...
Bilateral eyes with no
ptosis, equal distribution of hair on eyebrows and eye lashes
...
Pupils are PERRL, normal
convergence
...
Peripheral vision intact in all
fields
...
right eye with
noted mild retinopathic changes
...
Bilateral TMs intact, pearly gray, positive light reflex
...
Nasal mucosa is

© 2021 Walden University, LLC

Page 6 of 9

pink and moist, no septal deviation
...
Uvula midline
...
Noted dentition with no evidence of
infection or dental caries
...

Neck:
Neck supple, full ROM
...
No lymphadenopathy
...

Chest/Lungs:
Anterior and posterior chest are symmetrical
...
Clear to auscultation in all lobes
...
Resonant to
all percussed fields
...
78 L FEV1: 1
...
S1, S2
...
Bilateral
carotids without bruit, 2+, no thrill
...
no heaves or lifts
...
Capillary refill
Abdomen:
Abdomen is symmetrical, protuberant, and nontender
...
Coarse hair from umbilicus to pubis
...

Normoactive bowel sounds x 4 quadrants
...

No organomegaly
...

Musculoskeletal:
Bilateral upper and lower extremities with full ROM, no pain with movement, no
swelling or deformity
...
Graphesthesia and stereognosis
normal
...
Upper and lower DTRs
present and equal, 2+
...
Sensation is decreased to
bilateral plantar surface to monofilament
...
Upper lip with facial hair
...

Diagnostic results:
•

Spirometry: FVC: 1
...
549 L

ASSESSMENT:
•

General Adult Physical Exam

PLAN: This section is not required for the assignments in this course (NURS 6512) but
will be required for future courses
...
W
...
E
...
A
...
S
...
W
...
Seidel's
Guide To Physical Examination: An Interprofessional Approach (9th ed
...
Louis, Missouri: Elsevier
...
E
...
C
...
(2019)
...
St
...
Retrieved from
https://content
...
edu/content/dam/laureate/laureate-academics/wal/msnurs/nurs-6512-11wk/week-5/Week_5_Dains_Chap32
...
(2022)
...
shadowhealth
...
D
...
Guide to Clinical Documentation (3rd ed
...
A
...
)
Philadelphia, PA: F
...
Davis Company

---