Please complete the attached SOAP note with the information provided 5 citations/references no older than 5 years 

Week 9

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

PLAN:
This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

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Vitals

Student Documentation

Model Documentation

Vitals

BP 120/82 SPO2 – 99 RR – 15 T – 37.2

N/A

Health History

Student Documentation

Model Documentation

Identifying Data & Reliability

Ms. Tina Jones is a 28 years old African American female. Not married and does not have children, currently in relationship with a boyfriend. Presently living with her mother and young sister. Ms. Jones presents to our consult for physical assessment as she newly got hired by a new employer. She is alert, allowing the pertinent data and well articulate. She is able to maintain eye contact, appropriately communicate and engage in the assessment.

N/A

General Survey

Ms. Jones is alert, engaged in her health matters and compliant with the follow ups. Seating in upright posture, articulate, with not stressed appearance , groomed well nourished , appropriately dressed and maintains good hygiene.

N/A

Reason for Visit

” I came because I ‘am required to have a recent physical exam for the health insurance at my new job”

N/A

History of Present Illness

Ms. Jones 28 years old African American female that presented for physical examination for the insurance of new job. She states that she does not have any present medical concern. The patient does have history of Diabetes, asthma and High blood pressure. The patient was prescribed with metformin around 5 months ago during her last physical exam, and also was diagnosed with PCOS by ger gynecologist at this time birth control medication was prescribed. Ms Jones reports some side effects associated with metformin , but also stated that those side effects were managed using yogurt. She stated stopping the use of Advil for cramps. MS Jones claims to be feeling currently healthy and looking forward the new employment.

N/A

Medications

Advil for cramps occasionally Metformin 850 mg twice a day Flovent daily inhaler and Proventil as a recue inhaler , she is presently using estradiol as birth control medication.

N/A

Allergies

Not food allergies identified. Allergic to cats and dust , she is also allergic to penicillin that given her rushes.

N/A

Medical History

Ms, Jones was diagnosed with asthma when she was 2 years old, for which presently she use Flovent and Proventil in the morning and evening. She is allergic to cats and dust. She was

Nursing 6512
Advanced Health Assessment & Diagnostic Reasoning

Episodic/Focused SOAP Note
Review of Case #3
Week 9 Initial Post

Patient Initials: K. T. Age: 33 Gender: F Ethnicity:
African American

SUBJECTIVE DATA:

Chief Complaint (CC): “Drooping on the right side of face”

History of Present Illness (HPI): MH is a 33-year-old Caucasian female

presents to the office today with right side facial drooping that she

observed when she woke up this morning. She says that her right eye has

been watering constantly, and that she can’t stop drooling out of the right

side of her mouth. She denies any pain.

Medications:

Ibuprofen 200mg-2 PO as needed

Tylenol 325mg-2 PO every 4 hours as needed

Woman’s Multivitamin daily

Allergies: No Known Allergies

Past Medical History (PMH): Diagnosed with asthma when she was a

child. All immunizations are up to date. Denies ever having any surgeries

or hospitalizations.

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Social History: K. T. is a heterosexual, sexually active individual who

lives with her husband and children. She denies any tobacco, alcohol or

illicit drug use & wears her seatbelt whenever operating a motor vehicle.

She enjoys time with her family, evening walks with her children when

weather permits and front porch sitting with a good book in hand. She

denies any issues with sleep and reports getting approximately 8-10 hours

of sleep a night.

Family History: Both of her parents are still living. Her father is 55 with a

history of arthritis and hypertension. Her mother is 54 without any

significant health history. Her younger sister, age 30, does not have any

significant health history. She has two children, ages 7 & 5 who are

healthy.

Review of Systems (ROS):

General: No unexplained weight loss or weight gain, no decreased

appetite, no fever, chills or fatigue

HEENT: No blurred or loss of vision, no loss of hearing, hearing difficulty

or ringing in ears, no congestion, runny nose, sore throat or hoarseness,

no swelling/tenderness in lymph nodes.

Skin: No changes in skin such as rashes, lesions dryness or persistent

itching

Respiratory: No SOB, cough or sputum p

1

Week 9 Patient Comprehensive Exam

Walden University

NURS 6512 Advanced Health Assessment

Dr. Vijayarani Suresh

August 2, 2021

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2

Week 9 Patient Comprehensive Exam

Week 9
Shadow Health Comprehensive SOAP Note Template

Patient Initials: T.J. Age:28 Gender: female

SUBJECTIVE DATA:

Chief Complaint (CC): “I’m here because I need a physical for my new job.”

History of Present Illness (HPI): T.J. is a 28-year-old African American female who is
here today for a general physical for a new job as an accounting clerk soon. She is
oriented to person, place, and time. She is calm, pleasant, and attentive. T.J. has dressed
appropriately for the season and is a good historian.

Medications: Metformin 850mg BID, last dose this morning
Flovent Inhaler two puffs twice daily, last used this morning
Albuterol Inhaler for rescue hasn’t been used recently. She states approximately three
months ago and has only used it twice last year.
Drospirenone/Ethinyl estradiol birth control, one pill daily. She started taking these four
months ago and was prescribed by her GYN MD. Last dose this morning.
Ibuprofen and Tylenol as needed

Allergies: Cats: makes asthma worse. PCN: “Not sure; I have been told this since I was a
child.” Denies any food allergies. She denies latex allergy. She states she does have some
environmental allergies.

Past Medical History (PMH): The patient has asthma, PCOS, and Type II Diabetes. She
states she checks her glucose every morning, and they have been stable. She has had
GERD in the past; however, she isn’t currently taking medication. She has only been
hospitalized for asthma as a child that she remembers and never for surgery. The patient
denies any severe injuries that would impair her. T.J. was seen for heart palpitations that
since then have subsided. She has been monitoring her blood pressure as it has fluctuated
at times but has now been normal. Last menstrual cycle was approximately two weeks
ago. The patient has never been pregnant and is up to date on her immunizations except
for the influenza vaccine. She recently had a routine pap smear; however, she needs to be
educated on how to do self-breast exams, as she states she has only had a doctor perform
this and doesn’t know what to look for. She denies any depressive or anxiety symptoms.
She has never had thoughts of harming herself or others, and Sh