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SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic
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 runny
nose, 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:
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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, and
type 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:
