TINA JONES- WEEK 9 SH COMPREHENSIVE SOAP NOTE
ADVANCED HEALTH ASSESSMENT (WALDEN UNIVERSITY)
, lOMoARcPSD|44613495
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: TJ Age: 28 Gender: Female
SUBJECTIVE DATA:
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):
Presents for a general physical examination in preparation for her new
position as an accounting clerk at Smith, Stevens, Silver & Company. She
denies having any serious issues. She visited a gynecologist for a checkup
four months prior, during which a PCOS diagnosis was made, and a daily
birth control regimen was prescribed. She states that (Drospirenone/ethinyl
estradiol) is taken consistently every day with satisfactory symptom
management. She had a physical examination five months prior, during
which she was prescribed Metformin for her diabetes and a daily inhaler
every day for her asthma. Her vision is now clearer, and she no longer
experiences migraines after seeing an eye doctor three months ago. She
claims that metformin, a healthy diet, and exercise are helping her manage
her diabetes. She routinely monitors her blood sugar levels each day. The
last time a rescue inhaler was used was three months ago with usage
reducing to twice yearly. The patient keeps a journal and measures her peak
flow at home.
Medications:
• Metformin 850mg PO BID (last taken today)
• Flovent 110mcg/spray 2 puffs BID (last taken today)
• Proventil 90mcg/spray 2 puffs PRN for wheezing and shortness of breath
(last used 3months ago)
• Drospirenone/Ethinyl Estradiol Birth Control 1 tablet PO daily (last taken
today)
ADVANCED HEALTH ASSESSMENT (WALDEN UNIVERSITY)
, lOMoARcPSD|44613495
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: TJ Age: 28 Gender: Female
SUBJECTIVE DATA:
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):
Presents for a general physical examination in preparation for her new
position as an accounting clerk at Smith, Stevens, Silver & Company. She
denies having any serious issues. She visited a gynecologist for a checkup
four months prior, during which a PCOS diagnosis was made, and a daily
birth control regimen was prescribed. She states that (Drospirenone/ethinyl
estradiol) is taken consistently every day with satisfactory symptom
management. She had a physical examination five months prior, during
which she was prescribed Metformin for her diabetes and a daily inhaler
every day for her asthma. Her vision is now clearer, and she no longer
experiences migraines after seeing an eye doctor three months ago. She
claims that metformin, a healthy diet, and exercise are helping her manage
her diabetes. She routinely monitors her blood sugar levels each day. The
last time a rescue inhaler was used was three months ago with usage
reducing to twice yearly. The patient keeps a journal and measures her peak
flow at home.
Medications:
• Metformin 850mg PO BID (last taken today)
• Flovent 110mcg/spray 2 puffs BID (last taken today)
• Proventil 90mcg/spray 2 puffs PRN for wheezing and shortness of breath
(last used 3months ago)
• Drospirenone/Ethinyl Estradiol Birth Control 1 tablet PO daily (last taken
today)
