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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