AHA SOAP Note Comprehensive Health Assessment

Complaint

Pre-employment insurance physical exam

Asthma diagnosed at age 2 1/2. Albuterol inhaler for asthma exacerbations. Her last asthma exacerbation was three months ago. The last time she has been hospitalized for asthma was in high school. No intubations. Type 2 diabetes was diagnosed at age 24. She began metformin five months ago and initially had some gastrointestinal side effects which have since resolved. She monitors her blood sugar once daily in the morning, with average readings around 90. She has a history of hypertension, which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche at age 11. First sexual encounter at age 18. Never pregnant. The last menstrual period was two weeks ago. She was diagnosed with PCOS four months ago. For the past four months, her cycles have been regular (every four weeks) with moderate bleeding lasting five days and is taking the medication Yaz. She is in a new relationship with a male, but sexual contact has not yet been initiated. The patient stated that she plans to use condoms if and when sexual intercourse does occur. Tested negative for HIV/AIDS and STIs four months ago.

Current Home Meds:

• Fluticasone propionate, 110 mcg two puffs BID (last use: this morning)

• Metformin, 850 mg PO BID (last use: this morning)

• Drospirenone and Ethinyl estradiol PO QD (last use: this morning)

• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)

• Acetaminophen 500-1000 mg PO prn (headaches)

• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken six weeks ago)

Allergies:

• Penicillin: rash

• Denies food and latex allergies

• Allergic to cats and dust. When she is exposed to allergens, she states that she gets a runny nose, itchy and swollen eyes, and increased asthma symptoms.

• Father: deceased in a car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes

• Brother (Michael, 25): overweight

• Sister (Britney, 14): asthma

• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol

• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol

• Paternal grandmother: still living, age 82, hypertension

• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes

• Paternal uncle: alcoholism

• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

The patient Currently lives with her mother and sister. She plans to move into an apartment within the next month. She is excited to begin her new career in a couple of weeks at Smith, Stevens, Stewart, Silver & company. The patient has a group of friends with well-developed relationships. Tina’s religion is Baptist. She has close ties with members of her congregation, which she views as family. Her support system helps her manage stress and anxiety. She denies ever using tobacco products. States that she used marijuana from age 15 to 21. She denies the use of methamphetamines, cocaine, heroin, or prescription drugs. She occasionally drinks when out with friends but usually just two to three times a month. She reports that she typically only has around three alcoholic beverages when out. The patient says that her diet is much improved. Breakfast usually consists of a fruit smoothie and unsweetened yogurt. Lunch is typically a sandwich on white bread or low-fat pita. For dinner, she typically has a portion of protein and vegetables. For snacks, she consumes carrot sticks and apples. She denies drinking coffee but usually drinks one to two diet sodas every day. She has also improved her activity level lately. She exercises four to five times per week by taking a walk, going for a swim, or participating in yoga.

Genitourinary:

Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge, or itching.