SOAP NOTE
SOAP NOTE –
Comprehensive
Assessment – Tina
Jones – Shadow
Health Clinic –
Ryan Kent
1
, SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent
SUBJECTIVE:
Chief complaint (CC): “I came in because I'm required to have a recent physical
exam for the health insurance at my new job.”
History of present illness (HPI): Ms. Jones reports that she recently obtained
employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a
pre-employment physical prior to initiating employment. Today she denies any
acute concerns. Her last healthcare visit was 4 months ago, when she received
her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states
that the gynecologist diagnosed her with polycystic ovarian syndrome and
prescribed oral contraceptives at that visit, which she is tolerating well. She has
type 2 diabetes, which she is controlling with diet, exercise, and metformin, which
she just started 5 months ago. She has no medication side effects at this time.
She states that she feels healthy, is taking better care of herself than in the past,
and is looking forward to beginning the new job.
Allergies:
•Penicillin: rash
•Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens she states that
she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
Past medical history (PMH): Asthma diagnosed at age 2 1/2. She uses her albuterol
inhaler when she is around cats. Her last asthma exacerbation was three months
ago, which she resolved with her inhaler. She was last hospitalized for asthma in
high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began
metformin 5 months ago and initially had some gastrointestinal side effects which
have since dissipated. She monitors her blood sugar once daily in the morning
with average readings being around 90. She has a history of hypertension which
normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche,
age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four
months ago. For the past four months (after initiating Yaz) cycles regular (every 4
weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual
contact not initiated. She plans to use condoms with sexual activity. Tested
negative for HIV/AIDS and STIs four months ago.
Health Maintenance: Last Pap smear 4 months ago. Last eye exam three months
ago. Last dental exam five months ago. PPD (negative) ~2 years ago.
Immunizations: Tetanus booster was received within the past year, influenza is not
current, and human papillomavirus has not been received. She reports that she
believes she is up to date on childhood vaccines and received the meningococcal
vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in
car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad,
are in the home, locked in parent’s room.
Social history:
SOAP NOTE –
Comprehensive
Assessment – Tina
Jones – Shadow
Health Clinic –
Ryan Kent
1
, SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent
SUBJECTIVE:
Chief complaint (CC): “I came in because I'm required to have a recent physical
exam for the health insurance at my new job.”
History of present illness (HPI): Ms. Jones reports that she recently obtained
employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a
pre-employment physical prior to initiating employment. Today she denies any
acute concerns. Her last healthcare visit was 4 months ago, when she received
her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states
that the gynecologist diagnosed her with polycystic ovarian syndrome and
prescribed oral contraceptives at that visit, which she is tolerating well. She has
type 2 diabetes, which she is controlling with diet, exercise, and metformin, which
she just started 5 months ago. She has no medication side effects at this time.
She states that she feels healthy, is taking better care of herself than in the past,
and is looking forward to beginning the new job.
Allergies:
•Penicillin: rash
•Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens she states that
she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
Past medical history (PMH): Asthma diagnosed at age 2 1/2. She uses her albuterol
inhaler when she is around cats. Her last asthma exacerbation was three months
ago, which she resolved with her inhaler. She was last hospitalized for asthma in
high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began
metformin 5 months ago and initially had some gastrointestinal side effects which
have since dissipated. She monitors her blood sugar once daily in the morning
with average readings being around 90. She has a history of hypertension which
normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche,
age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four
months ago. For the past four months (after initiating Yaz) cycles regular (every 4
weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual
contact not initiated. She plans to use condoms with sexual activity. Tested
negative for HIV/AIDS and STIs four months ago.
Health Maintenance: Last Pap smear 4 months ago. Last eye exam three months
ago. Last dental exam five months ago. PPD (negative) ~2 years ago.
Immunizations: Tetanus booster was received within the past year, influenza is not
current, and human papillomavirus has not been received. She reports that she
believes she is up to date on childhood vaccines and received the meningococcal
vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in
car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad,
are in the home, locked in parent’s room.
Social history:
