An In-Depth SOAP Note Tina Jones’s Shadow Health Evaluation
the name Jones
: 28 years old
the female gender
African American is their race.
The main issue is that “I want to get a physical for the health insurance at her new job.”
History of complaint: Ms. Jones, an African American woman of 28 years old who was most recently employed by the Steven Stewart and Silver firm, wants to have a pre-employment medical. She says she has no urgent worries.
850 mg of metformin PO BD
The last morning medications to utilize are drospirenone and Ethinyl estradiol PO QD.
Albuterol spray, 90 mcg MDI two puffs Last used three months ago for Q4H PRN.
Ibuprofen 600 mg and acetaminophen 500-600 mg PO PRN Menstrual cramps PO TID PRN last took 6 weeks ago
The last used this morning was Fluticasone Propionate 110mcg 2puffs BID.
88mcg of Flovent 2 puffs spray BID
90mcg of Proventil 2puffs PRN spray
one tablet per day of Yaz for PCOS
Allergies: After taking penicillin, the patient breaks out in a rash. when exposed to dust and cats, develops a runny nose, itchy, and swollen eyes, and worsens asthma symptoms. She uses a rescue inhaler, bathes, avoids the allergen, and treats the allergy. She denies having a latex or food allergy.
Past medical history: The patient has the polycystic ovarian syndrome, diabetes mellitus, hypertension, and asthma. She has been taking her medicine for her asthma since she was two years old. She utilizes albuterol while near cats and claims to have been hospitalized for an acute exacerbation, although she never had an intubation. Three months ago, she had her most recent asthmatic flare-up, which she was able to treat with her inhaler. Since the age of 24, the patient has had type 2 diabetes mellitus. She has been taking her medicine on a regular basis, and today’s reading of her blood sugar was 90. She has a history of hypertension, which diet and exercise have helped to regulate. Four months ago, she received a polycystic ovarian syndrome diagnosis.
She denies having had any major or minor surgical operations in the past.
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History of sexual activity and conception: The patient had his or her first sexual experience at the age of 18. She is straight and intends to wear a condom when she meets her new lover for the first time. Her tests for STIs and HIV/AIDS came back negative. She hadn’t had a period in three weeks. Before using Yaz for four months, she had an erratic cycle; she is now regular after every four weeks. She has never given birth.
History of health maintenance: The patient frequently receives booster vaccinations, and eye, dental, and pap smear exams. Her most recent pap smear revealed normal results four months ago. Her most recent dental checkup was five months ago, and her most recent eye exam was three months ago. She had all of her childhood vaccinations on time, her most recent tetanus shot was less than a year ago, and she hasn’t yet received her influenza and human papilloma vaccines. She does not ride a bike, applies sunscreen, has smoke alarms in her home, buckles up while driving, and utilizes seat belts. Locked in her parents’ room are firearms that belonged to her father.
Social background: Ms. Jones is unmarried, childless, and has been living on her own since she was 19 years old. Currently, she lives with her mother and sister, but she intends to move into her own apartment the following month. She will start working at the Smith, Steven, Stewart, and Silver firm in two weeks. She likes going to bible studies, dancing, reading, serving in the church, and hanging out with her friends. She characterizes the church, where she is involved, as a strong community and social support structure. According to her, stress is managed through the family and the church. She acknowledges using alcohol while she goes out with her pals at least three times each month, for a total of three drinks per outing. She used marijuana from the age of 19 to 21 in the past. She claims not to have used heroin, cocaine, meth, or tobacco. She usually has a frozen fruit smoothie with plain yogurt for breakfast. Her supper consists of roasted vegetables and protein, and her snack is either carrots or an apple. For lunch, she eats veggies with brown rice, a sandwich on wheat bread, or a low-fat pita. Denies drinking coffee, but does drink 1-2 diet sodas daily. No overseas trip recently. No pet walks, does yoga, or goes swimming four to five times a week as mild to moderate exercise.
Family background: She is the family’s firstborn. Her mother, who is 50 years old, has high blood pressure and high cholesterol. Her brother, 25, is overweight. Her 14-year-old sister suffers from asthma. Her 82-year-old paternal grandma has hypertension, and her paternal uncle is an alcoholic. At the age of 58, her father lost his life in a car accident. But throughout his life, he struggled with high cholesterol, high blood pressure, and type 2 diabetes. Her paternal grandpa died of colon cancer at the age of 67. The diseases of hypertension, stroke and hypercholesterolemia claimed the lives of her maternal grandparents. Colon cancer, hypertension, diabetes mellitus, stroke, hypercholesterolemia, asthma, and obesity are examples of chronic disorders that run in families. There is no confirmed history of mental illness or sickle cell disease.
History of mental health: She has enhanced coping skills and decreased stress levels. She disputes having sadness, anxiety, or suicidal thoughts, however.
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In general, the patient is not experiencing tiredness, weight loss, night sweats, fever, or chills and rigors.
HEENT: The patient claims to have no neck discomfort, sore throat, runny nose, headache, blurred vision, eye pain, head trauma, or jaw pain.
Cardiovascular: The patient disputes the existence of any orthopnea, paroxysmal nocturnal dyspnea, syncope, dyspnea, palpitations, or chest discomfort.
The patient denies experiencing breathing problems, coughing, sputum production, chest discomfort, or wheezing.
Gastrointestinal system: The patient disputes experiencing heartburn, reflux, nausea, diarrhea, or vomiting.
Genitourinary system: The patent disputes hematuria, flank discomfort, dysuria, polyuria, vulval itching, and lower stomach pain.
Musculoskeletal System: The patient disputes any discomfort or swelling in their muscles, backs, necks, or joints.
Psychiatric: The patient disputes the existence of suicidal thoughts, hallucinations, anxiety, sleeplessness, mood swings, and anxiety.
Neurologic system: The patient denies experiencing headaches, vertigo, changes in her posture and gait, resting trembles, bodily weakness, face drooping, tingling, or numbness.
Skin, hair, and nails: The patient reports less acne, more evenly distributed face and body hair, and a halt to the darkening of the neck caused by contraceptives. She disputes having breakouts, brittle nails, hair loss, and skin rashes.
The patient is seated upright on the examination table in general. She is composed, awake, and focused. She doesn’t have lymphadenopathy, pallor, jaundice, edema, cyanosis, or dehydration.
Vitals: BMI of 29.0, temperature of 99.0°F, HR of 78, blood sugar level of 100, RR of 15, BP of 128/82, and pulse rate of 99%.
HEENT: The head is cephalic and uninjured. Her lashes and brows are evenly distributed in both directions. Her eyelids are free of edema and lesions. The sclera is white, the conjunctiva is pink, and there is no lesions present. The pupils are equally sized, rounded, and receptive to light on both sides. There is no nystagmus and the EOMs are intact bilaterally. On the right, there are slight retinopathy alterations. Sharp discs with margins are seen in the left fundus. There is no bleeding. The Snellen test results for the right and left eyes with corrective lenses are both 20/20. The TMs are healthy, pearly gray on both sides, and have a good light reflex. There is bilateral hearing of whispered speech. When palpated, the frontal and maxillary sinuses are not sensitive. Pink, moist nasal mucosa with a midline septum. The uvula is midline on phonation, the oral mucosa is moist, and there are no ulcerations or abnormalities. The gag reflex is still functional. absence of infection or obvious cavities in the teeth. She has smooth thyroid tissue without nodules, goiter, or lymphadenopathy, and bilateral tonsils that are 2+.
respiratory system: The chest expansion is symmetrical and normal in the anterior and posterior halves. Over the chest, there are no painful spots. A resonating percussion sound may be heard. On auscultation, the lung fields are discernible. In tune with percussion FVC measurement: 3.91 L; FEV1/FVC ratio: 80.56%
The heart is located in the fifth intercostal space, or mid-clavicle line, in the cardiovascular system. S1 and S2 of the heart are audible. The rhythm and pace of the heartbeat are predictable. There aren’t any heaves, thrills, gallops, or rubs, however. Without bruit, the carotid and peripheral pulses are bilaterally equal. Less than 3 seconds pass during the capillary refill. There is no edema in either lower limb.
Gastrointestinal system: Each of the patient’s four abdominal quadrants has a normal shape. No organs have become larger. One centimeter below the coastal border is the liver span. Kidneys and the spleen are not palpable. Every quadrant has a tympanic percussion note. However, there isn’t any pulsing dullness or flowing exhilaration. In all four quadrants, the gut sounds are typical and lively.
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Musculoskeletal System: None of the four limbs are swollen or deformed. In both the lower and upper limbs, the muscular strength is five out of five bilaterally. Reflexes, the muscular mass, and tone are all unaltered. The limbs may move in all directions. The act of moving causes no discomfort.
Neurological system: The patient’s motions alternate quickly on both sides. Cerebella function tests come up clean. She has a typical stereotype. In both plantar surfaces, monofilament is decreased.
Skin, hair, and nails: The patient has a typical scar, acne on her face, facial hair at the top of her lip, and an obvious, old scar on her left shin. She has normal-appearing nails.
Diagnostic Tests: Because the patient has diabetes mellitus, renal function tests to examine the fluid and electrolyte balance are the right tests for her. She needs a liver function test to rule out fatty liver disease since she is overweight and has a drinking history (Jara, et al, 2019). Lipid profile to rule out hyperlipidemia due to her weight issues.
The patient also suffers from the polycystic ovarian syndrome, asthma, hypertension, and type 2 diabetes mellitus. Her vital signs—random blood sugar at 100 mg/dl and blood pressure at 128/82 mmHg—are within the normal range. The patient has a BMI of 29, is overweight, and wears glasses. Her family has had strokes, high blood pressure, alcoholism, colon cancer, diabetes mellitus, and hypercholesterolemia.
The patient’s primary diagnosis was asthma and managed diabetes mellitus in addition to polycystic ovarian syndrome. A metabolic condition called diabetes mellitus is characterized by elevated blood glucose levels brought on by inadequate insulin synthesis (Oguntibeju, O. O. 2019). Vision blurring, tingling, numbness, polyuria, polyphagia, and polydipsia are symptoms of the condition. Lifestyle choices including drunkenness, inactivity, genetic susceptibility, and comorbidities are causes. The patient’s blood sugar is under good control since she downplays her symptoms. She does, nonetheless, have the polycystic ovarian syndrome, which worsens insulin sensitivity.
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