Week 9
Shadow Health Comprehensive SOAP Note
Patient Initials: __T.J_____ Age: __28_____ Gender: __Female_____
SUBJECTIVE DATA:
Chief Complaint (CC): Complete health assessment for pre-employment physical.
History of Present Illness (HPI): Tina Jones is 28 years old African American woman with a medical history of asthma, uncontrolled Typer-2-diabetes, and obesity. She visited the clinic due to her new job physical requirement. She stated no acute health problem at this time. She last visited her gynecologist 4 months ago for her annual gynecological exam. She started taking her birth control medication to manage her polycystic ovary syndrome and had her general physical exam 5 months ago. She was non complaint with her metformin due to side effect of upset stomach, but she reports eating probiotic yogurt with the medicine. She currently manage her blood sugar diet, exercise, and her metformin twice daily. She currently check her blood sugar once a day in the morning, which is usually around 90. She reported improved overall vision since her last optometric visit 3 months ago. Reports reduction in blurry vision. Patient denies headache or SON. No recent asthma exacerbations. Last was 3 months ago. She reports improved blood pressure with diet and exercise changes. She reports her last menstrual period was 2 weeks ago, which last for 5 days. She stated that her menstrual periods usually comes with cramps and medium flood every 4 weeks.
Medications:
Metformin 850mg PO BID
Yaz (drospirenone and ethinyl estradiol) same time daily
Flovent inhaler BID
Proventil rescue inhaler PRN- Last used three months ago
Advil 200 mg PRN–rare use for cramps
No OTC herbal products
No OTC vitamins
No OTC supplements
Allergies:
Penicillin– Hives and rashes
Cats— Sneezing, wheezing and itchy eyes
No known food, seasonal or latex allergy.
Past Medical History (PMH):
Asthma
Type-2-diabetes
Hyper
Past Surgical History (PSH):
None
Sexual/Reproductive History:
Patient is currently in a month relationship with no sexual partner. Plan to use condom during sexual intercourse.
Personal/Social History:
Patient usually drinks about 2 or 3 drinks occasionally. 2-3 nights per month. No smoking or illicit drug use. She reports less caffeine due to her heart rate and sleep disorder. No coffee but gets her only caffeine through from 2 diet coke per day. She mentioned changed to her diet and exercise for good and have lost about 10 pounds from change in diet and increase exercise. She reports mild to moderate exercise by walking four to five times a week for about 30 or 40 minutes and weekly swimming at YCMA. No asthma attack during exercise.
Health Maintenance:
Patient have a good change in her health compared to her last doctors visit. She changed her diet and increased her exercise regimen. She continue to take her medications and keep up with her medical appointments. He blood sugar and blood pressure are within stabilized. She reports feeling less stress and ability to cope with stress after her graduation and passing her CPA exam. No depression. And reports coping well with upcoming life changes. She denies difficulty sleeping and sleeps about 8 to 9 hours per night. She currently stay with her mom and sister and have a good support system from family, friends, and church.
Immunization History:
Tetanus booster a year ago.
Childhood immunizations up to date
College required immunization
Up to date in all vaccinations
Significant Family History:
- Mother is alive and has high cholesterol and hypertension. Mother drinks win occasionally. Father died from car accident and had history of type 2 diabetes, high cholesterol, and hypertension.
- Sister has Type-2-diabetes.
- Brother is Obese
- Paternal grandmother is 82, she has history of hypertension and high cholesterol
- Paternal grandfather died from colon cancer. He had history of hypertension and diabetes.
- Maternal grandfather died. He had hypertension and high cholesterol.
- Maternal grandmother died five years ago at age 73 from stroke. She had history of high blood pressure and high cholesterol.
Review of Systems:
General: Patient report no recent or illness. Denies fatigue, chills, or fever. No night sweats.
Head- Denies any recent head injury.
Ear- Reports no ear pain or discharge. No change in hearing or tinnitus.
Eyes- Denies itchy eyes, redness, or dry eyes.
Nose- Denies rhinorrhea. No nosebleed or sinus pain or pressure. Reports no change in sense of smell.
Throat- Denies dysphagia, sore throat, or voice change. No problem with lymph nose or swollen glands
Breast: Denies any breast bumps or pain.
Respiratory: Reports no difficulty breathing. No coughing or chest tightness
Cardiovascular/Peripheral Vascular: Denies chest pain, palpitation, or irregular heartbeat. Reports no edema or circulation issues.
Gastrointestinal: Denies diarrhea, constipation, nausea or vomiting. No stomach pain.
Genitourinary: Denies dysuria, bilateral flank pain or blood in urine. No virginal itching or irritations
Musculoskeletal: Reports no muscle weakness or joint pain
Neurological: Denies numbness and tingling. No seizure history or loss of sensation. Reports no balance problems
Psychiatric: Denies depression. Improved anxiety, and no suicidal ideation.
Skin/hair/nails: Reports no dry skin or rashes. slow-healing wound.
OBJECTIVE DATA:
Physical Exam:
Vital signs:
BP: 128/82, HR. 78, Spo2_ 99%, RR_15, Temp_ 37.2C,Weight_ 90 kg, Height_ 5’7
Lung capacity FVC_3.91L and FEV1/FVC ratio is 80.56%.
General: Patient is alert and oriented X4. She remain calm and dressed appropriately
Head-Normocephalic, atraumatic with normal scalp hair distribution. Scattered pustules on face. No mass noted.
Eyes-No ptosis or edema noted. Equal hair on lashes. Conjunctiva pink, no lesions, and white sclera. Right and left PERRL. No nystagmus. Intact peripheral vision. No vision problem noted
Ear- Right and left tympanic membrane intact and pearly gray. Bilateral positive light reflex. No hearing problem noted.
Nose- Mucosa moist and pink. Septum midline on right and left nose.
Throat- Gag reflex intact. Oral mucosa moist without ulceration lor lesions.
Neck: Acanthosis nigricans noted. No nodule noted on the thyroid. No goiter, or neck stiffness
Cardiovascular: Right and left carotid pulse 2+, with no thrill or bruit. 2+ in all pulses. Normal heart rhythm S1, S2. No murmur or gallop noted. No bruit noted in all arteries. No edema in all extremities. Cap refill < 3 sec. PMI palpated at the midclavicular, 5th intercostal space.
Respiratory: Chest wall and thoracic expansion rises symmetrical, no deformity. Clear lung sound with no adventitious sounds.
Abdomen: Protuberant, symmetrical with no masses or lesion. Normoactive in all quadrants. No bruit noted from aortic artery. No CVA tenderness noted. Soft and no rebound with deep palpate
Musculoskeletal: Upper and lower extremities equal without mass, or deformities. Full ROM in all extremities. Upper and lower extremities strength 5/5. No weakness noted
Neurological: Noted decreased sensation in right and left foot. Light touch, dull pain, and sharp pain sensation intact on both arms and legs.
Skin/nail: No rash of wound noted. Nails intact, no ridge or abnormal toenails and fingernails
Psychiatric: No distress or anxiety noted. Patient remain calm and answer all questions
Start Here
Diagnostic results: Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned.
ASSESSMENT: list a minimum of 3 differential diagnoses and justify why you selected each with evidence literature). Your primary or presumptive diagnosis should be at the top of the list (#1).
Shadow Health Comprehensive SOAP Note
Patient Initials: __T.J_____ Age: __28_____ Gender: __Female_____
SUBJECTIVE DATA:
Chief Complaint (CC): Complete health assessment for pre-employment physical.
History of Present Illness (HPI): Tina Jones is 28 years old African American woman with a medical history of asthma, uncontrolled Type-2-diabetes, and obesity. She visited the clinic due to her new job physical requirement. She stated no acute health problem at this time. She last visited her gynecologist 4 months ago for her annual gynecological exam. She started taking her birth control medication to manage her polycystic ovary syndrome and had her general physical exam 5 months ago. She was non complaint with her metformin due to side effect of upset stomach, but she reports eating probiotic yogurt with the medicine. She currently manage her blood sugar diet, exercise, and her metformin twice daily. She currently check her blood sugar once a day in the morning, which is usually around 90. She reported improved overall vision since her last optometric visit 3 months ago. Reports reduction in blurry vision. Patient denies headache or SON. No recent asthma exacerbations. Last was 3 months ago. She reports improved blood pressure with diet and exercise changes. She reports her last menstrual period was 2 weeks ago, which last for 5 days. She stated that her menstrual periods usually comes with cramps and medium flood every 4 weeks.
Medications:
Metformin 850mg PO BID
Yaz (drospirenone and ethinyl estradiol) same time daily
Flovent inhaler BID
Proventil rescue inhaler PRN- Last used three months ago
Advil 200 mg PRN–rare use for cramps
No OTC herbal products
No OTC vitamins
No OTC supplements
Allergies:
Penicillin– Hives and rashes
Cats— Sneezing, wheezing and itchy eyes
No known food, seasonal or latex allergy.
Past Medical History (PMH):
Asthma
Type-2-diabetes
Hyper
Past Surgical History (PSH):
None
Sexual/Reproductive History:
Patient is currently in a month relationship with no sexual partner. Plan to use condom during sexual intercourse.
Personal/Social History:
Patient usually drinks about 2 or 3 drinks occasionally. 2-3 nights per month. No smoking or illicit drug use. She reports less caffeine due to her heart rate and sleep disorder. No coffee but gets her only caffeine through from 2 diet coke per day. She mentioned changed to her diet and exercise for good and have lost about 10 pounds from change in diet and increase exercise. She reports mild to moderate exercise by walking four to five times a week for about 30 or 40 minutes and weekly swimming at YCMA. No asthma attack during exercise.
Health Maintenance:
Patient have a good change in her health compared to her last doctors visit. She changed her diet and increased her exercise regimen. She continue to take her medications and keep up with her medical appointments. He blood sugar and blood pressure are within stabilized. She reports feeling less stress and ability to cope with stress after her graduation and passing her CPA exam. No depression. And reports coping well with upcoming life changes. She denies difficulty sleeping and sleeps about 8 to 9 hours per night. She currently stay with her mom and sister and have a good support system from family, friends, and church.
Immunization History:
Tetanus booster a year ago.
Childhood immunizations up to date
College required immunization
Up to date in all vaccinations
Significant Family History:
- Mother is alive and has high cholesterol and hypertension. Mother drinks win occasionally. Father died from car accident and had history of type 2 diabetes, high cholesterol, and hypertension.
- Sister has Type-2-diabetes.
- Brother is Obese
- Paternal grandmother is 82, she has history of hypertension and high cholesterol
- Paternal grandfather died from colon cancer. He had history of hypertension and diabetes.
- Maternal grandfather died. He had hypertension and high cholesterol.
- Maternal grandmother died five years ago at age 73 from stroke. She had history of high blood pressure and high cholesterol.
Review of Systems:
General: Patient report no recent or illness. Denies fatigue, chills, or fever. No night sweats.
Head- Denies any recent head injury.
Ear- Reports no ear pain or discharge. No change in hearing or tinnitus.
Eyes- Denies itchy eyes, redness, or dry eyes.
Nose- Denies rhinorrhea. No nosebleed or sinus pain or pressure. Reports no change in sense of smell.
Throat- Denies dysphagia, sore throat, or voice change. No problem with lymph nose or swollen glands
Breast: Denies any breast bumps or pain.
Respiratory: Reports no difficulty breathing. No coughing or chest tightness
Cardiovascular/Peripheral Vascular: Denies chest pain, palpitation, or irregular heartbeat. Reports no edema or circulation issues.
Gastrointestinal: Denies diarrhea, constipation, nausea or vomiting. No stomach pain.
Genitourinary: Denies dysuria, bilateral flank pain or blood in urine. No virginal itching or irritations
Musculoskeletal: Reports no muscle weakness or joint pain
Neurological: Denies numbness and tingling. No seizure history or loss of sensation. Reports no balance problems
Psychiatric: Denies depression. Improved anxiety, and no suicidal ideation.
Skin/hair/nails: Reports no dry skin or rashes. slow-healing wound.
OBJECTIVE DATA:
Physical Exam:
Vital signs:
BP: 128/82, HR. 78, Spo2_ 99%, RR_15, Temp_ 37.2C,Weight_ 90 kg, Height_ 5’7
Lung capacity FVC_3.91L and FEV1/FVC ratio is 80.56%.
General: Patient is alert and oriented X4. She remain calm and dressed appropriately
Head-Normocephalic, atraumatic with normal scalp hair distribution. Scattered pustules on face. No mass noted.
Eyes-No ptosis or edema noted. Equal hair on lashes. Conjunctiva pink, no lesions, and white sclera. Right and left PERRL. No nystagmus. Intact peripheral vision. No vision problem noted
Ear- Right and left tympanic membrane intact and pearly gray. Bilateral positive light reflex. No hearing problem noted.
Nose- Mucosa moist and pink. Septum midline on right and left nose.
Throat- Gag reflex intact. Oral mucosa moist without ulceration lor lesions.
Neck: Acanthosis nigricans noted. No nodule noted on the thyroid. No goiter, or neck stiffness
Cardiovascular: Right and left carotid pulse 2+, with no thrill or bruit. 2+ in all pulses. Normal heart rhythm S1, S2. No murmur or gallop noted. No bruit noted in all arteries. No edema in all extremities. Cap refill < 3 sec. PMI palpated at the midclavicular, 5th intercostal space.
Respiratory: Chest wall and thoracic expansion rises symmetrical, no deformity. Clear lung sound with no adventitious sounds.
Abdomen: Protuberant, symmetrical with no masses or lesion. Normoactive in all quadrants. No bruit noted from aortic artery. No CVA tenderness noted. Soft and no rebound with deep palpate
Musculoskeletal: Upper and lower extremities equal without mass, or deformities. Full ROM in all extremities. Upper and lower extremities strength 5/5. No weakness noted
Neurological: Noted decreased sensation in right and left foot. Light touch, dull pain, and sharp pain sensation intact on both arms and legs.
Skin/nail: No rash of wound noted. Nails intact, no ridge or abnormal toenails and fingernails
Psychiatric: No distress or anxiety noted. Patient remain calm and answer all questions
Start Here
Diagnostic results:
Hemoglobin A1C (HbA1c) test: This is the standard test for diabetes (Mayo Clinic, 2021). The test has generated an HbA1c value of 7.1%.
Spirometry: This is the standard test for asthma (Saglani & Menzie-Gow, 2019). Results have shown evidence of airway obstruction.
Ultrasound of the ovaries: This test is used to examine the ovaries to test the presence of cysts (Johns Hopkins Medicine, 2021). Results have revealed the presence of fluid-filled sacs in the ovaries.
ASSESSMENT:
Tina Jones has stated that she does not have any acute health problems at the moment. Her reason for visiting the clinic today is to obtain a complete health assessment for pre-employment physical. Subjective and objective findings indicate that the patient has medical conditions that had been diagnosed before and that she is currently taking medications to manage them. In in this respect, it is not necessary to list differential diagnoses in her case. A list of differential diagnoses is normally prepared when a patient reports to the clinic complaining of either acute or chronic symptoms whose diagnoses have not been confirmed. Using the list, the healthcare provider usually performs a number of diagnostic tests to rule out some of the conditions and confirm the primary diagnosis (Kammer et al., 2021). Since Tina Jones does not have any acute health problems at the moment, the medical conditions that should form the basis of her treatment plan are type 2 diabetes, asthma, and polycystic ovary syndrome. These are not differential diagnoses but multiple conditions that have been confirmed before and that are still present today.
References
Johns Hopkins Medicine. (2021). Polycystic ovary syndrome (PCOS). https://www.hopkinsmedicine.org/health/conditions-and-diseases/polycystic-ovary-syndrome-pcos
Kämmer, J. E., Schauber, S. K., Hautz, S. C., Stroben, F., & Hautz, W. E. (2021). Differential diagnosis checklists reduce diagnostic error differentially: A randomised experiment. Medical Education, 55(10):1172-1182. doi: 10.1111/medu.14596. Epub 2021 Aug 18. PMID: 34291481.
Mayo Clinic. (2021). Type 2 diabetes. https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199
Saglani, S., & Menzie-Gow, A. N. (2019). Approaches to asthma diagnosis in children and adults. Frontiers in Pediatrics, 7, 148. https://doi.org/10.3389/fped.2019.00148.