IHUMAN CASE STUDY: LAURA WOOD – COMPLETE SOAP
NOTE FOR A 41-YEAR-OLD FEMALE WITH ROUTINE
WELL-WOMAN EVALUATION, PREHYPERTENSION, AND
MILD MORNING JOINT STIFFNESS (WEEK 9)
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Laura Wood
Age 41 years old
Gender Female
Height 5'5" (165 cm)
Weight 140 lb (64 kg)
BMI 24 (Normal range)
Occupation Project manager / Middle school teacher
Source Patient (self)
Reliability Reliable, alert, and able to provide clear history
Allergies No Known Drug Allergies (NKDA)
Reason for Encounter: "Here for my routine well-woman check-up; overall I
feel healthy, but I want to make sure I'm up to date with screenings and
prevention."
, Encounter Type: Outpatient primary care clinic – routine annual well-woman
evaluation
Week 9 Focus: Comprehensive preventive health assessment, age-appropriate
screening recommendations, and lifestyle counseling for a healthy middle-aged
female.
PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details Relevance
Denies hypertension, diabetes, thyroid Healthy
No chronic illnesses
disease baseline
No prior
Except for childbirth
hospitalizations
Immunizations Up to date
Key Points:
Generally healthy with no significant past medical history
No history of abnormal Pap smears
No history of breast disease or abnormalities
Last Pap smear 3 years ago – normal
PART 3: PAST SURGICAL HISTORY (PSH)
Surgery Year Details
None N/A No prior surgeries
Note: Two prior hospitalizations for childbirth only
, PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
Daily Standard Self- General
Once daily
multivitamin dose prescribed health
No prescription
N/A N/A N/A N/A
medications
Key Points:
No OTC medications regularly
No herbal supplements
No hormone therapy
PART 5: FAMILY HISTORY (CRITICAL for Risk Assessment)
Relative Age Condition(s) Relevance
First-degree
Breast cancer at age
Mother [Living] relative – MAJOR
55
risk factor
Type 2 diabetes,
Father [Living] Metabolic risk factor
Hyperlipidemia
No family history of
Other [Not
colon, ovarian, or uterine
relatives specified]
cancer
, Family History Risk Summary
Risk Factor Present in Laura
First-degree relative with breast cancer (mother, age
✓ YES
55)
✓ YES (age 55 is
Premenopausal breast cancer in relative
premenopausal)
Multiple affected relatives ✗ NO (only mother reported)
Ovarian cancer in family ✗ NO
Colorectal cancer in family ✗ NO
Key Point: Mother's breast cancer diagnosis at age 55 places Laura
at increased risk for breast cancer and may warrant earlier or more frequent
screening .
PART 6: REPRODUCTIVE HISTORY
Parameter Details Risk Implicatio
Age at menarche Not specified
Menstrual cycle Regular, every 28-30 days, lasting 4-5 days Normal
Gravida/Para G2P2
Age at first pregnancy Not specified
Breastfeeding Not specified
Menopausal status Premenopausal
NOTE FOR A 41-YEAR-OLD FEMALE WITH ROUTINE
WELL-WOMAN EVALUATION, PREHYPERTENSION, AND
MILD MORNING JOINT STIFFNESS (WEEK 9)
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Laura Wood
Age 41 years old
Gender Female
Height 5'5" (165 cm)
Weight 140 lb (64 kg)
BMI 24 (Normal range)
Occupation Project manager / Middle school teacher
Source Patient (self)
Reliability Reliable, alert, and able to provide clear history
Allergies No Known Drug Allergies (NKDA)
Reason for Encounter: "Here for my routine well-woman check-up; overall I
feel healthy, but I want to make sure I'm up to date with screenings and
prevention."
, Encounter Type: Outpatient primary care clinic – routine annual well-woman
evaluation
Week 9 Focus: Comprehensive preventive health assessment, age-appropriate
screening recommendations, and lifestyle counseling for a healthy middle-aged
female.
PART 2: PAST MEDICAL HISTORY (PMH)
Condition Details Relevance
Denies hypertension, diabetes, thyroid Healthy
No chronic illnesses
disease baseline
No prior
Except for childbirth
hospitalizations
Immunizations Up to date
Key Points:
Generally healthy with no significant past medical history
No history of abnormal Pap smears
No history of breast disease or abnormalities
Last Pap smear 3 years ago – normal
PART 3: PAST SURGICAL HISTORY (PSH)
Surgery Year Details
None N/A No prior surgeries
Note: Two prior hospitalizations for childbirth only
, PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
Daily Standard Self- General
Once daily
multivitamin dose prescribed health
No prescription
N/A N/A N/A N/A
medications
Key Points:
No OTC medications regularly
No herbal supplements
No hormone therapy
PART 5: FAMILY HISTORY (CRITICAL for Risk Assessment)
Relative Age Condition(s) Relevance
First-degree
Breast cancer at age
Mother [Living] relative – MAJOR
55
risk factor
Type 2 diabetes,
Father [Living] Metabolic risk factor
Hyperlipidemia
No family history of
Other [Not
colon, ovarian, or uterine
relatives specified]
cancer
, Family History Risk Summary
Risk Factor Present in Laura
First-degree relative with breast cancer (mother, age
✓ YES
55)
✓ YES (age 55 is
Premenopausal breast cancer in relative
premenopausal)
Multiple affected relatives ✗ NO (only mother reported)
Ovarian cancer in family ✗ NO
Colorectal cancer in family ✗ NO
Key Point: Mother's breast cancer diagnosis at age 55 places Laura
at increased risk for breast cancer and may warrant earlier or more frequent
screening .
PART 6: REPRODUCTIVE HISTORY
Parameter Details Risk Implicatio
Age at menarche Not specified
Menstrual cycle Regular, every 28-30 days, lasting 4-5 days Normal
Gravida/Para G2P2
Age at first pregnancy Not specified
Breastfeeding Not specified
Menopausal status Premenopausal
