Soap Note
Soap Note 1 \”ADULT\” Wellness check-up (10 points)
Follow the following as a guides:
Use APA format and must include mia minimum of 2 Scholarly Citations.
Solution
Wellness check up
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor:
Soap Note # ____ Main Diagnosis: The patient is in good health
PATIENT INFORMATION
Name: J.L
Age: 37 years
Gender at Birth: Male
Gender Identity: Male
Source:
Allergies: No known allergies reported.
Current Medications: The patient is not using any medications at the moment.
PMH: As per J.L.’s medical records, he was diagnosed with malaria at the age of 7 years. He was treated as an outpatient without hospitalization.
Immunizations: Available medical records indicate that J.L. received all immunizations according to schedule.
Preventive Care: J.L. engages goes to the gym every morning. He reports eating balanced diet with a lot of fruits and vegetables.
Surgical History: Denies surgical history.
Family History: Both parents are still alive. He reports that no member of his family has been diagnosed with a serious medical condition before.
Social History: J.L. is happily married with two children, a girl and a boy. He further reports that he is a responsible father and a faithful husband. He denies consuming alcohol and smoking cigarettes.
Sexual Orientation: Male
Nutrition History: J.L. does not eat foods with excess fats. He only eats white meat but not red meat. He drinks a lot of water and eat a lot of fresh fruits and vegetables. J.L. denies a history of diagnosis with a nutrition-related conditions such as marasmus, kwashiorkor, bulimia nervosa, or obesity.
Subjective Data:
Chief Complaint: “I have come to the clinic today for a wellness checkup.”
Symptom analysis/HPI:
The client is a 37-year-old white called John Learts. His main reason for visiting the clinic today is that he wants the doctor to conduct a wellness checkup as part of physical medical exam that he does after every four year. His last wellness checkup was done 4 years ago.
Review of Systems (ROS)
CONSTITUTIONAL: J.L. does not report significant weight loss. He does not report fever or vomiting. He reports feeling generally healthy.
NEUROLOGIC: No issues reported.
HEENT: J.L. does not report any health problems in the head, ears, eyes, nose, mouth, and throat.
RESPIRATORY: Does not report problems with breathing, either exhalation or inhalation.
CARDIOVASCULAR: J.L. denies chest pain or chest congestion.
GASTROINTESTINAL: Does not report constipation, abdominal pain, or stomachache.
GENITOURINARY: Denies issues with the genitals or urination-related complications.
MUSCULOSKELETAL: J.L. does not report joint pain or body weakness.
SKIN: Denies itchiness or rashes.
Objective Data:
VITAL SIGNS: Height: 54.3 inches; Weight: 158 lb; RR: 20; HR: 92; BP: 130/80; Oxygen saturation: 99%; Temperature: 37.2 degrees Celsius.
GENERAL APPEARANCE: The patient healthy and attentive. He is appropriately dressed for the weather and is well-groomed and. He properly asks and responds to questions.
NEUROLOGIC: Fingers and toes have good coordination. Both upper and lower limbs are sensitive to pain.
HEENT:
Head: Head is Normocephalic with no evidence of physical injury/trauma. He has hair densely distributed throughout the scalp. No lymphadenopathy. No masses on the scalp. The frontal and maxillary sinuses lack tenderness.
Eyes: Visual acuity at 20/20. Hair on lashes and eyebrows are black perfectly distributed. Absence of lesions on the eye lids, no edema on both eyes. The conjunctiva is pink and has no lesions. The sclera is white. The pupil is reactive to light and responds to changes in light stimuli. Absence of hemorrhage on the fundus. Does not use corrective lenses.
Ear: Both ears and symmetrically positioned on both sides of the head. They both respond adequately to changes in sound stimuli. The tympanic membranes of both ears are pearly-grey in color and are intact.
Nose: The nasal mucosa is without lesions. It is hairy, moist, and pink. The two nostrils are separating into two equal halves by the septum.
Throat: Absence of erythema in the throat.
CARDIOVASCULAR: Complete capillary refill takes less than 3 seconds. Absence of murmur. Absence of bruit in the arteries. No edema in the legs.
RESPIRATORY: Absence of lesions or deformity on the chest walls. Both lungs contract and relax properly during exhalation and inhalation respectively. No adventitious sounds like wheezing.
GASTROINTESTINAL: Absence of tenderness, absence of masses. No lesions are observed. Percussion of the spleen does not reveal any evidence of dullness.
MUSKULOSKELETAL: Nail ridges are absent. No joint pain or deformity. J.L. has a normal gait and balance.
INTEGUMENTARY: The skin is hairy, warm, and moist. Rashes, lesions, and dryness are absent. No redness observed.
ASSESSMENT:
Patient J.L. came to the clinic for a wellness checkup without any chief complaint. He states that he decided to get a wellness check-up today because has been long since he lastly saw a doctor. From his subjective and objective data, a conclusion has been made that patient J.L. is in good health.
Main Diagnosis
- None based on the subjective and objective data.
Differential diagnosis
- Patient J.L. is in good health (Dains et al., 2016).
PLAN:
Labs and Diagnostic Test to be ordered
- – None
Pharmacological treatment:
–None/not necessary.
Non-Pharmacologic treatment:
-None/not necessary.
Education
- J.L. has been advised to continue going to the gym to keep fit and healthy.
- He has been educated about the benefits of eating a healthy and balanced diet.
- J.L. has been advised to ensure that he drinks at least of 8 glasses of water per day and to always remember to eat fruits daily (Aman & Masood, 2020).
Follow-ups/Referrals
- The patient was informed to visit the clinic anytime he feels strange symptoms.
- No referrals were necessary considering the fact that J.L. did not have any health complications.
References
Aman, F., & Masood, S. (2020). How nutrition can help to fight against COVID-19 Pandemic. Pakistan Journal of Medical Sciences, 36(COVID19-S4), S121–S123. https://doi.org/10.12669/pjms.36.COVID19-S4.2776
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.