Comprehensive Assessment SOAP Note: Tina Jones - NURS 623, Exams of Nursing

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NURS 623 Ryan Kent SOAP Note Comprehensive Assessment

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 runnynose, 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:

Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.

Family history:

• Mother: age 50, hypertension, elevated cholesterol
• Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, andtype 2 diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
• Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82, hypertension
• Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia,thyroid problems

Current medications:

• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
• Metformin, 850 mg PO BID (last use: this morning)
• Drospirenone and ethinyl estradiol PO QD (last use: this morning)
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)
• Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)Review

of systems (ROS):

HEENT:

Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge.

Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.

Cardiovascular: Reports no palpitations, tachycardia, easy bruising, or edema.

Respiratory: Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.

Abdominal: Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.

Musculoskeletal: Reports no muscle pain, joint pain, muscle weakness, or swelling.

Integumentary: Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

Neurological: Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

Psychiatric: Psychosocial / Mental Health: Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation.

Speech is fluent, words are clear.

OBJECTIVE:

Vital signs:

• Height: 170 cm
• Weight: 84 kg
• BMI: 29.
• Blood Glucose: 100
• RR: 15
• HR: 78
• BP:128 / 82
• Pulse Ox: 99%
• Temperature: 99.0 F

Physical exam (PE):

GEN: Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.

HEENT: Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

RESPIRATORY: Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

CARDIOVASCULAR: Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

MUSCULOSKELETAL: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

ABDOMINAL: Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

INTEGUMENTARY: Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.

NEUROLOGIC: Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

ASSESSMENT:

Tina Jones comes in for a follow-up/general physical exam. She is now on metformin, Proventil, and Flovent. She has glasses following a vision exam. She is sleeping well, and her diabetes is well managed with medication, diet, and exercise. She regularly monitors her blood sugar levels and feels more comfortable with her knowledge regarding the meaning of the readings. She has begun keeping records of her asthma by monitoring her peak flow and tracking the use of her rescue inhaler. She is in a relationship and is now on birth control, which is helping to control her PCOS.

Diagnosis - [N/A] Pre- employment physical

PLAN:

[N/A] Pre- employment physical

Patient Education:

Patient verbalizes understanding of exam and procedures explained to her prior to assessment. Patient denies any further concerns at this time.