WEEK 4 SOAP NOTE Annual physical PDF

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AnnualPhy s i c al Ex ami na t i o n:Adul t Ki mbe r l yKa yMa r i n Uni t e dSt a t e sUn i v e r s i t y

2 ANNUAL PHYSICAL SUBJECTI VE: I D: Cl i e nt ’ sI ni t i a l s :MA Ag e :3 1y e a r sol d Ge nd e r :Fe ma l e Ra c e :As i a n, Fi l i pi no Da t eofBi r t h:Oc t o be r18, 1 98 9 Ma r i t a ls t a t us : Si n g l e Me di c a lI ns ur a nc e :Bl u eShi e l d CC:“ Ia mdu ef ora na nnu a lph y s i c a la n dIne e dt ob ee s t a bl i s he df orane wdo c t or ” . HPI :Pa t i e nt ’ sl a s ta nnu a lph y s i c a lwa sJ a nu a r y20 20.Ac c or d i n gt ot hep a t i e nt ,t he r ewe r eno a bn or ma lph y s i c a lfind i n g sa ndl a bor a t or yt e s t sa tt ha tt i me .Shepe r f o r msBSEmo s t l ye v e r yd a y bu ts ome t i me sf or g e t swhe ns hei si nahu r r yf o rwor k .He rl a s td e n t a le x a mwa sDe c e mbe r202 0 a ndl a s te y ee xa mwa sSe p t e mbe r20 20. Ot he r wi s e , noo t he rc ompl a i n t sorc on c e r ns . Pas tMe di c alHi s t or y :Nop a s tme di c a lhi s t or y, ps y c hi a t r i ci l l ne s s e sori n f e c t i o usdi s e a s e s . Pas tSur ge r i e s / Hos pi t al i z at i o ns :De ni e sa n yr e c e nts ur g e r i e s . De ni e sr e c e ntho s pi t a l i z a t i on s . Me di c at i o ns :Shei sno tt a ki n ga n yp r e s c r i be do rOTCme di c a t i on s .Sh ea l s od oe sno tt a k ea n y s up pl e me nt sora n yhe r ba ls upp l e me nt s . Al l e r gi e s :Nod r u ga l l e r gi e s . Noe n vi r onme nt a la ndf o oda l l e r gi e s . I mmuni z a t i ons :I nflu e nz av a c c i ne-11 / 20 20 .Tda pbo os t e r–09 / 20 11.Compl e t ewi t hc hi l dh oo d i mmu ni z a t i onsbu ts hedoe sno tr e me mbe rt hee xa c tda t e s . Sh ewi l le ma i lc op i e sf ort hec l i ni c . Di e t :Shea v oi d sf a s tf o od , s a l t yf ood ,s we e t sa nds oda .Shee a t sawho l epl a t eofs a l a de v e r y me a l ,a nds her a r e l ye a t spo r kbut ma i nl y , ha sc hi c k e na ndfis h.Sh edr i nk sbe t we e n8 10gl a s s e s ofwa t e re a c hda y . Shedo e sno tdr i n ke ne r gyd r i nksorc o ffe e . Ex e r c i s e / Sl e e p/ St r e s s :Sh edoe spo we ry o g aa ndme di t a t i one v e r ymor ni n g ,whi c hhe l p swi t hh e r s t r e s s .Sh eh a snop r ob l e mswi t hs l e e pi n ga ndha sa tl e a s t7h our sofs l e e pe a c hn i ght . Subs t anc eus e / Smoki ngHi s t or y :Nons mok e ra nds hedo e sno tdr i nka l c oh ol . Noh i s t o r yofu s e ofi l l i c i tdr u g s . Soc i alHi s t or y/ Se xua lHi s t or y :Pa t i e nt i ss i n g l ea ndl i v e si na na pa r t me ntwi t hhe rc o us i ns . Sh e wor ksa sy o g ai ns t r uc t ora nda non c a l lr e g i s t e r e dnur s e . Sh ec on s i de r she r s e l fa sahe t e r os e xu a l

3 ANNUAL PHYSICAL wi t hama l epa r t ne rf o r5y e a r s . Shea dmi t st or a r e l yu s i n gp r o t e c t i o na n dt he yha v eno tg ot t e n t e s t e df o rSTDsr e c e nt l y . Fami l yHi s t or y: ● MGM i s85y e a r sol dwi t hh i s t or yofh y pe r t e ns i ona ndb ph. ● MGFd i e da ta g e84y e a r sol dduet os t r o k ea ndh a dh y pe r t e ns i on . ● P GM -u nkno wn. ● P GF-un kno wn. ● Mo t h e ri s6 3y e a r sol d, n okno wnme di c a li l l n e s s e s . ● F a t he r-un kn o wn. Re vi e wofSy s t e ms : ● Co n s t i t ut i o na l–De ni e swe i gh t , we a kne s s , f e v e rorc hi l l s ● E y e s-De ni e sc ha n g e si nv i s i on , bl u r r yvi s i on ,e x c e s s i v ee y edi s c ha r g e , dr ye y e s , floa t e r sor e y epa i n . ● Ea r s / Nos e / Mou t h/ Thr o a t-Ea r s :De ni e st i n ni t us , e a r a c hea ndde c r e a s e di nhe a r i n g . Nos e : De ni e sr un n yn os e , e pi s t a xi sorde c r e a s e di ns me l l i n g .Thr oa t / Mou t h:De ni e ss or et hr o a t , or a l l e s i on sors or e s ,v oi c eho a r s e ne s sdi ffic ul t y/ pa i nf uls wa l l o wi n g , f a c i a lp a i n, p os t na s a ldr i por j a wpa i n . ● Ca r di o v a s c ul a r–De ni e sc he s tdi s c omf or t , pa l pi t a t i ons , c he s tpa i n, orl e ge de ma . ● Re s pi r a t or y–De ni e ss ho r t ne s sofb r e a t h,he mop t y s i s , whe e z i n g , pl e ur i t i cpa i no rc o ug hi n g . ● GI–He rno r ma lbo we lpa t t e r ni se v e r yda y .De ni e sa n yna us e a ,he ma t e me s i s ,me l e n a , di a r r he a , v omi t i n g , c ons t i pa t i onora n yb l oo d ys t oo l . ● GU–De ni e spa i nf u lur i na t i o n,f r e q ue ntur i na t i on ,noc t ur i aa ndhe ma t ur i a . ● Mu s c ul os k e l e t a l–De ni e sj oi ntpa i n, mus c l epa i n, b a c kpa i n, s wol l e nj oi nt s , s t i ffj oi nt sor wa l ki n gd i ffic u l t i e s . ● I nt e g ume nt a r y–De ni e sr a s he s , i t c hi n g , dr yn e s sora n yg e ni t a ll e s i o ns . ● En d oc r i ne–De ni e si nc r e a s e dt h i r s t , hu n g e r , c ol dorho ti nt ol e r a nc ea nde x c e s s i v es we a t i n g . ● Ne ur o l o gi c a l–De n i e snu mbne s s , di z z i n e s s , he a da c heorp a r e s t he s i a . ● P s y c hi a t r i c / Me nt a lHe a l t h–De ni e st hou g ht sofs ui c i de ,s a dn e s sa nda nx i e t y . ● He ma t ol o g i c / Lymph a t i c–De ni e sa n ys wol l e na ndp a i nf ull ymphnod e s . ● Al l e r g i e s–Non e wa l l e r g i e s . OBJECTI VE: Vi t a ls i g ns :  Te mpe r a t ur e–97 . 7  He a r tr a t e–86b pm  Re s pi r a t or yr a t e–2 0  Bl oo dpr e s s ur e–11 2/ 86  Oxy g e n–10 0% He i gh t-5’ 2” We i ght–119po und s BMI–2 1. 8

4 ANNUAL PHYSICAL ● Ge ne r a l-Pa t i e nt i sa l e r ta ndo r i e nt e d . Sh el ook swe l lk e mpt .Sheha snos i gn sofa c ut e di s t r e s s . Shea ns we r squ e s t i on sa ppr o pr i a t e l ya ndma i nt a i n e dg oo de y ec on t a c t . Shei sag oo d hi s t or i a n. ● HEENT– He ad:Ev e nl yd i s t r i bu t e dha i rwi t ht h i c kt e x t u r e . Nol u mps , c y s t s , de pr e s s i on sa nd he ma t o ma spa l p a t e d. Fac e :Fa c ei ss ymme t r i c a lwi t hnos i gn soft r a uma . Nof a c i a ldr o opi n g . TMJi snon t e nd e r wi t hmob i l i t yi nt a c t . Fa c i a ls e ns a t i oni nt a c t . Ey e s :Nop t o s i sorr e dne s sone y e l i d s . Noe x c e s s i v el a c r i ma t i on.Ey e l a s he se v e nl yd i s t r i bu t e d. Con j unc t i v ai spi n k. Non t e nd e rl a c r i ma ldu c t s . Sc l e r ai swhi t e . I r i si si nt a c ta ndr ou nd . Cl e a r c or ne a , nos i gn sofa br a s i on . Po s i t i v er e dr e fle x. Vi s ua la c ui t y :20/ 20OS, OD, OU.Vi s ua l fie l di nt a c t . EOM i nt a c t .+PERRLA.BC.Pos i t i v ewhi s pe rt e s t . We be r mi d l i ne . Nos e :Na r e si nt a c t . Nod e f o r mi t i e s . Non t e nd e rs i nu s e s . Pi nkna s a lmuc os awi t h outb o gg y t ur b i na t e . Sme l l i n gi nt a c t . Mou t h/ Thr oa t :Or a lmuc os ai spi n ka ndmoi s t . Node nt a lde f or mi t i e s , or a ls or e s ,s i gn sof i n f e c t i onorbl e e di n g . Ton g uei si nt a c t . Pa l a t ei nt a c t . Uvul ami dl i n ea ndr i s e sdu r i n g“ a hh” t e s t . +1Gr a d et on s i l s . Swa l l o wi n gr e fle xi nt a c t . Ga gr e fle xi si nt a c t . ● Ne c k-Nopa l pa b l ema s s e s . Tr a c he ai smi d l i ne . Non t e nde r ,s ymme t r i c a lt h y r oi dg l a ndwhi c h e l e v a t e sons wa l l o wi n g . ROM i n t a c ti nne c ka nds ho ul de rwi t h5/ 5s t r e n gt h. ● Ca r di o v a s c ul a r–S1a ndS2he a r ts ou nds .Nomur mu r sore xt r ahe a r ts oun ds . +2r a di a lpul s e s a ndpe da lpu l s e s .Ca pr e fil li sl e s st ha n3s e c on ds . Nob r ui t sonc a r ot i d. ● Re s pi r a t or y-Noc y a nos i s , c he s twa l ld e f o r mi t i e sorus eofa c c e s s or ymus c l e s . Che s tr i s e s s ymme t r i c a l l y . Re s ona nc epr e s e ntonpe r c us s i o n. Cl e a rl un gs oun ds . ● GI / GU–Abd ome ni snon di s t e nd e d. Nor moa c t i v ebo we ls ou nd s . Tympa ni conpe r c us s i on . Li v e rs pa ni s7c m. Noo r g a no me g a l y . Ne g a t i v eCVAt e nd e r ne s sa ndki dne y snon p a l pa bl e . ● Mus c ul os k e l e t a l– He ada ndNe c k :Sy mme t r i c a lwi t hROM i nt a c t . Upp e rEx t r e mi t i e s , Han ds , Fi n g e r s , El bo wsan dS hou l de r s :ROM i nt a c t , nos we l l i n gor t e nde r ne s s . Sy mme t r i c a l . Lowe rEx t r e mi t i e s , Kne ean d/ Ank l e s :ROM i nt a c t . Sy mme t r i c a l . Not e nde r ne s sors we l l i n g . Hi p sandSp i ne :ROM i n t a c t . Nopa i no rs we l l i n g . ● I nt e g ume nt a r y–Ski ni si n t a c t . Noo pe nl e s i on s , di s c ol o r a t i o n,b r ui s e sorr a s he s . ● Ne ur o l o gi c a l–Re f e rt oHEENTf o rCr a ni a ln e r v e sa s s e s s me nt .Spe e c hi sc l e a r .Ba l a nc e d g a i t . Se ns a t i o none xt r e mi t i e si nt a c t . 5/ 5s t r e n gt h. +2d t r . ● He ma t ol o g i ca ndLy mph a t i c :Nol y mph a de nop a t h y . ASSESSMENT: c oun t e rf org e ne r a la dul tme di c a le x a mi na t i onwi t ho uta bno r ma lfindi n g s 1.En I CDZ00 . 00

5 ANNUAL PHYSICAL Ce nt e r sf o rDi s e a s eCon t r o la ndPr e v e nt i o n( CDC)( 20 17)r e c omme ndst ope r f o r m r ou t i nea n nua lph y s i c a le xa mi na t i on sa n dl a b or a t o r yt e s t st ohe l pi de nt i f yh e a l t hpr o bl e ms f ori mme di a t et r e a t me nta ndma na g e me nt . Thi spa t i e ntn e e dst oha v ehe ra nnu a lph y s i c a l f ort hi sy e a r . 2.En c oun t e rf ori mmun i z a t i o n I CDZ23 I ti sr e c omme nde dt ha ta du l t sr e c e i v eas i n g l edo s eofTda pa n df o l l o we db yTdo raTd a p bo os t e re v e r y10y e a r s( Ce nt e r sf o rDi s e a s ec on t r o la ndPr e v e nt i o n[ CDC] , 202 0) . Pa t i e nt i supd a t e dwi t hi mmu ni z a t i on se x c e pt f o rTda p. c oun t e rf ors c r e e ni n gf o ri n f e c t i on swi t hapr e do mi na nt l ys e xu a lmod eoft r a ns mi s s i on 3.En I CDZ11 . 3 U. S. Pr e v e nt i v eSe r vi c e sa ndTa s kFor c e( USPSTF)( n. d . )r e c omme n dsSTDs c r e e ni n g whi c ha l s oi nc l u de sHI Va nds yph i l i sba s e do nt hepa t i e nt ’ shi s t o r y . Pa t i e nti ss e xu a l l y a c t i v ea nda dmi t st on otu s i n gp r ot e c t i on . Sheha sno tha da n ySTDs c r e e n i n g . PLAN: Labo r at o r yt e s t s / Di a gnos t i ct e s t s : CBC CMP FLP TSH UA Vi t a mi nD STDpa ne lt e s t Th e s ea r er e c omme nd e dt oa s s e s sf o rr i s kf a c t or sf o rc ommonhe a l t hpr o bl e mss uc ha s di a be t e sme l l i t us , h yp e r l i p i de mi a , h y pe r t e ns i on , vi t a mi nd e fic i e nc i e s , t h yr o i di s s ue sa nd s e xua l l yt r a ns mi t t e di l l ne s s e s( Vi e r a ,2 020 ) . Me di c at i o n/ Vac c i nat i o n:Te t a nus / Re du c e dDi p ht he r i at o x oi ds , a c e l l ul a rpe r t us s i sv a c c i ne ( Td a p)( Boo s t r i x)0. 5mLI M x1( Hi b be r d, 2 02 0) . Educ a t i o n: 1.Con s umehe a l t h yb a l a nc e ddi e twi t hl o wc a r boh ydr a t e s , f a ta nds od i um, l e s s e ne dr e dme a t a ndhi g hi nv e g e t a bl e sa ndf r ui t s( Vi e r a , 2 02 0) . Cont i nuet od r i nk810g l a s s e sofwa t e r e a c hd a y( Vi e r a , 2 020 ) . 2.Ph y s i c a la c t i vi t y :Ae r obi ce x e r c i s e s3t i me se a c hwe e k, t ot a lof1 50mi nu t e spe rwe e k ( Vi e r a , 20 20) .

6 ANNUAL PHYSICAL 3.Mo ni t ora n yc ha n g e si nhe a l t h .Forl i f et hr e a t e ni n gi s s ue s , c a l l91 1. Fol l o wup:Re t ur nt oc l i ni ca f t e rt wowe e k sf o rr e vi e wofl a bo r a t o r yr e s ul t s . Ma yc a l lo rma k ea n a pp oi nt me nte a r l i e rf o rur g e nthe a l t hc o nc e r ns . Sc he du l ene xta nnu a lph y s i c a lf o rJ a nua r y20 22.

Re f e r e nc e s : Diphtheria, tetanus, and pertussis vaccine recommendations. (2020). Centers for Disease Control and Prevention. Retrieved January 31, 2021 from https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/recommendations.html Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved February 1 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoidvaccination-in-adults Re gu l arc he c k up sar ei mpo r t ant .( 20 17 ) .Ce nt e r sf orDi s e a s eCon t r o la ndPr e v e n t i on. Re t r i e v e d onJ a nu a r y31 ,202 0f r omhttps://www.cdc.gov/family/checkup/index.htm Recommendation topics. (n.d.). U.S. Preventive Services Task Force. Retrieved January 31, 2021 from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics Vi e r a ,A. ( 202 0) . Ov e r vi e wofpr e v e nt i v ec a r ei na dul t s . UpT oDat e .Re t r i e v e donJ a nua r y31 , 20 21f r omhttps://www.uptodate.com/contents/overview-of-preventive-care-in-adults? search=annual%20physical %20exam&source=search_result&selectedTitle=1~150&usage_type=default&display_ra nk=1#H553116813...