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S.O.A.P. Note CASE ID# Tina Comprehensive Assessment
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
ComplaintChief
What brought you here
Pre-employment insurance physical exam
today (e.g., headache)
Chronological order of events, state of health before the onset of CC
Onset Ms. Jones came into the clinic today, stating that she recently obtained
Location employment at Smith, Stevens, Stewart, Silver & Company. She
Duration reported the need to get a pre-employment physical before she can start
Character work. The patient denies any acute problems or concerns. Her last
Aggravating/associated healthcare visit was four months ago. She received her annual
History of
Present
Illness
factors gynecological exam and stated that the gynecologist diagnosed her with
Relieving factors the polycystic ovarian syndrome and prescribed oral contraceptives at
Temporal factors – other that visit. The patient reports that she is tolerating the new medication
things going on well. She has type two diabetes, which she is controlled with diet,
exercise, and metformin. The patient reports she began taking metformin
five months ago and is compliant with her regimen. She has no
Severity medication side effects at this time. She states that she has felt an
improvement in her health as of late. Ms. Jones says that she is taking
better care of her health and is excited to begin her new career.
Adult Illnesses, childhood
Medical
History
illnesses, immunizations, Asthma diagnosed at age 2 1/2. Albuterol inhaler for asthma
Past
surgeries, allergies, exacerbations. Her last asthma exacerbation was three months ago. The
current medications last time she has been hospitalized for asthma was in high school. No
intubations. Type 2 diabetes was diagnosed at age 24. She began
Include Parents, siblings; • Mother: age 50, hypertension, elevated cholesterol
History
Family
grandparents if • Father: deceased in a car accident one year ago at age 58,
applicable/known, cause hypertension, high cholesterol, and type 2 diabetes
of death, age, pertinent • Brother (Michael, 25): overweight
medical illnesses • Sister (Britney, 14): asthma
Education, marital status,
Personal/Social
occupation, alcohol/drug The patient Currently lives with her mother and sister. She plans to move
use, smoking status, into an apartment within the next month. She is excited to begin her new
History
sexual history if relevant, career in a couple of weeks at Smith, Stevens, Stewart, Silver &
exercise, nutrition, company. The patient has a group of friends with well-developed
religious preference if relationships. Tina’s religion is Baptist. She has close ties with members
known of her congregation, which she views as family. Her support system
helps her manage stress and anxiety. She denies ever using tobacco
Review of Systems
The patient reports a recent weight loss of 10 pounds due to exercise
General: and an improved diet. The patient denies current frequent illnesses,
fevers, chills, night sweats, or other symptoms of concern.
Hair, Skin, & Nails: No abnormalities reported
Head: Denies recurring headaches or other abnormalities
Neck: No abnormalities reported
Eyes: Denies recent changes in vision
This study source was downloaded by 100000830772748 from CourseHero.com on 02-23-2022 05:19:16 GMT -06:00
Ears: No abnormalities reported
https://www.coursehero.com/file/62216532/AHA-SOAP-Note-Tina-Comprehensive-Health-Assessmentdocx/
S.O.A.P. Note CASE ID# Tina Comprehensive Assessment
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
ComplaintChief
What brought you here
Pre-employment insurance physical exam
today (e.g., headache)
Chronological order of events, state of health before the onset of CC
Onset Ms. Jones came into the clinic today, stating that she recently obtained
Location employment at Smith, Stevens, Stewart, Silver & Company. She
Duration reported the need to get a pre-employment physical before she can start
Character work. The patient denies any acute problems or concerns. Her last
Aggravating/associated healthcare visit was four months ago. She received her annual
History of
Present
Illness
factors gynecological exam and stated that the gynecologist diagnosed her with
Relieving factors the polycystic ovarian syndrome and prescribed oral contraceptives at
Temporal factors – other that visit. The patient reports that she is tolerating the new medication
things going on well. She has type two diabetes, which she is controlled with diet,
exercise, and metformin. The patient reports she began taking metformin
five months ago and is compliant with her regimen. She has no
Severity medication side effects at this time. She states that she has felt an
improvement in her health as of late. Ms. Jones says that she is taking
better care of her health and is excited to begin her new career.
Adult Illnesses, childhood
Medical
History
illnesses, immunizations, Asthma diagnosed at age 2 1/2. Albuterol inhaler for asthma
Past
surgeries, allergies, exacerbations. Her last asthma exacerbation was three months ago. The
current medications last time she has been hospitalized for asthma was in high school. No
intubations. Type 2 diabetes was diagnosed at age 24. She began
Include Parents, siblings; • Mother: age 50, hypertension, elevated cholesterol
History
Family
grandparents if • Father: deceased in a car accident one year ago at age 58,
applicable/known, cause hypertension, high cholesterol, and type 2 diabetes
of death, age, pertinent • Brother (Michael, 25): overweight
medical illnesses • Sister (Britney, 14): asthma
Education, marital status,
Personal/Social
occupation, alcohol/drug The patient Currently lives with her mother and sister. She plans to move
use, smoking status, into an apartment within the next month. She is excited to begin her new
History
sexual history if relevant, career in a couple of weeks at Smith, Stevens, Stewart, Silver &
exercise, nutrition, company. The patient has a group of friends with well-developed
religious preference if relationships. Tina’s religion is Baptist. She has close ties with members
known of her congregation, which she views as family. Her support system
helps her manage stress and anxiety. She denies ever using tobacco
Review of Systems
The patient reports a recent weight loss of 10 pounds due to exercise
General: and an improved diet. The patient denies current frequent illnesses,
fevers, chills, night sweats, or other symptoms of concern.
Hair, Skin, & Nails: No abnormalities reported
Head: Denies recurring headaches or other abnormalities
Neck: No abnormalities reported
Eyes: Denies recent changes in vision
This study source was downloaded by 100000830772748 from CourseHero.com on 02-23-2022 05:19:16 GMT -06:00
Ears: No abnormalities reported
https://www.coursehero.com/file/62216532/AHA-SOAP-Note-Tina-Comprehensive-Health-Assessmentdocx/
