Comprehensive Soap Note
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Vitals
BP: 128/82 mm Hg
Sp02 99% RA
PULSE : 78
Temp 37.2 C
Weight 84 kgs
Height 170cm
Health History
Identifying Data
MS Jones is a 28 year old African American woman who presented for a pre-physical
She is the primary source of the health information and freely
Provides the information
Her speech is clear and coherent
She maintains eye contact throughout the interview
General Survey
Ms. Jones is alert/oriented to time, place, event and person
She is appropriately dressed and does not manifest any distress
Reason for Visit
History of Present Illness
Ms. Jones is a 28 –year old African American woman who presented
For a pre-employment physical.
She is the primary source of the health information and freely provides the information.
Her speech is clear and coherent
She maintains eye contact throughout the interview.
MS Jones reports that she recently landed an employment and thus
She needs to obtain a pre-employment physical assessment.
She denies any pain acute illness, pain or discomfort.
PAST MEDICAL HISTORY
Diabetes
PCOS
Asthma
Allergies
Medications
Metformin: 850 mg BID
Flovent: 2 puffs 88 mcg/spray BID
Albuterol: 90 mcg/spray MDI 2 puffs
Ibuprofen 600 mg PO TID
Medical History
Asthma diagnose 2 years ago uses albuterol. Last exacerbation
Was 3 months ago?
Type 2 diabetes diagnose at 24 years old, started metformin 5 months
Ago
Has a history of hypertension
Diagnosed with PCOS four months ago
Family History
Never married
Has a boyfriend
Enjoys attending church activities and spending time with friends
No tobacco or any drugs use
Social drinker
Eats healthy diet
Physically active
Mother: Hypertension, high cholesterol
Father: Deceased at 58, hypertension, type 2 diabetes, high
Cholesterol
Brother: Overweight
Sister: Asthma
Maternal grandmother: Succumbed to stroke, history of
Hypertension, high cholesterol
Maternal grandfather: died of stroke, history of high blood pressure and
High cholesterol
Paternal grandmother: High Blood pressure and high cholesterol
Paternal grandfather: colon cancer, high blood pressure, diabetes
Health Maintenance
Last Pap smear 4 months ago
Last dental exam, 5 months ago
Immunizations: Tetanus booster within the last year, influenza not updated
Consumes healthy diet and engages in exercises
Mental History
Reports reduced stress
Denies depression or anxiety
Orient to time, place, person and event
Fluent speech
Subjective:
Reports no current headache
No visual changes
Reports no change in smell
No current dental problems
Denies no soar throat
Denies any difficulty swallowing
Cardiovascular:
Denies chest pain, dyspnea on excretion, edema, lightheadness, Scalp is normal
Heart rate is regular without murmurs, rubs or gallops
Bilateral carotids equal without bruit.
Bilateral peripheral pulses equal bilaterally
Capillary refill less than 3 seconds
PMI at the midclavicular
Head is normocephalic
Bilateral eyes: sclera white, no cross eyes.
Conjunctivitis pink
Oral mucosa pink
Gag reflex intact
Thyroid smooth with nodules, no lypadedenopathy
Frontal and maxillary sinuses nontender to palpate
Respiratory:
No cough, crackles, hemoptysis, no sob, no cough, no wheezing, chest is
Symmetric with respiration clear to auscultation bilaterally
Resonant to percussion throughout
Gastrointestinal
Denies: abdominal pain, constipation, diarrhea, flatus, melena, nausea, vomiting
Musculoskeletal
Reports: no symptoms (neck pain, shoulder pain back pain, upper extremity pain –
Lower, extremity pain joint swelling, denies muscle pain, muscle weakness or swelling
Skin:
Reports: improved acne after using oral contraceptives.
Skin and neck has stopped darkening and facial and body hair has improved. Denies any nail changes. No symptoms pruritus denies cyanosis, diaphoresis, dryness jaundice, mottled
No rashes, sores. nail free of ridges or abnormalities
Neurological:
Reports: no symptoms gait disturbance, tremors,
Denies aphasia, confusion, numbness, speech changes, tingling. Loss of coordination, seizures or sense of disequilibrium.
Psychiatric:
Reports: No cravings (ETOH) depression, denies agitation, anxiety, hallucinations, Homicidal ideation, mood lability, suicidal ideation;
Endocrine
Denies cold intolerance, heat intolerance, denies polydipsia, denies polyphagia,
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