1

SOAP: Geriatric Annual Exam

Subjective:

ID: J.J.a 70 y/o Caucasian female. May 3, 1953. She is a reliable historian. Presents to the clinic

with her daughter whom she lives with.

CC: “ I came for my annual exam”

HPI: The patient is a 70-year-old caucasian female. Presenting for annual physical. No

complaints. Last noted physical exam 14 months ago. Diagnosed with prediabetes on last exam.

PMH

Medical Problem list: Positive for prediabetes

Surgeries / Hospitalization: Cholecystectomy twenty years ago

Immunizations: UTD on immunizaitons. She received her annual flu shot 11/12/2022. She has

also had 2 Covid Vaccinations and 2 booster shots. Her last Covid booster was also on

11/12/2022

Allergies: No food allergies. No drug allergies, No environmental allergies

Medications: Positive for MVT only

Family History: adopted and has one daughter whom she lives with.

Chemicals: Patient denies any alcohol, tobacco, or drug use

Diet/exercise/caffeine: Patient gives her measurements as sixtyfour inches and 155 pounds.

She is active and attends chair exercise class at her local YMCA. She states she rarely eats fast

food.
 3

Sexual/Reproductive History: States her last period was at 58 years old, she can not remember

the exact date. She states she is not currently sexually active. She has not been in a relationship

since the death of her husband 8 years ago due to colon cancer.

Social History

Occupation/habitation: Patient states she is retired. She worked at an elementary school in the

cafeteria. She states she lives with her daughter, son-in-law, and 3 grandchildren. She moved in

with them after the death of her husband to be closer to family and help with the grandchildren.

Spiritual/Social Supports: She is Catholic and participates in mass at her church. She has

supportive friends from the church.

Safety: Drives and uses a seatbelt at all times. There is no gun in the home. She denies any

history of domestic or partner violence or violence in her previous home or current home.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: J.J. is a 70 y/o caucasian female. She is alert and oriented to time,

person, place, and situation. She is a reliable historian. No acute distress noted.

EYES: Patient wears glasses for reading. Denies any issues with her eyes

EAR/NOSE/THROAT/MOUTH: Denies any issues with hearing. Denies any ear pain.

Denies nasal discharge , bleeding. Denies pain in her throat. Has a bridge in the lower right and

upper front 3 teeth.

CARDIOVASCULAR: denies any chest pain, or palpitations. She also denies any leg swelling

or pain with exertion or pain at leg pain at rest.

RESPIRATORY: She denies any wheezing, shortness of breath or cough

GASTROINTESTINAL: She reports occasional constipation and mild straining, she states that

eating cooked prunes help. Negative abdominal pain, n/v diarrhea, negative hematochezia,
 4

GENITOURINARY: No issue with urination. No frequency, No pain with urination, No blood

in the urine .

MUSCULOSKELETAL: No issue with pain in the joints. No pain in the calves when walking

or at rest. No edema in the legs.

INTEGUMENTARY: No issue with skin, No rashes, No sores, No dry skin. No issue with

skin of the breast.

NEUROLOGY: No neurological issues. No headaches or dizziness. No issues with memory.

No body or extremity weakness

PSYCHIATRIC: No mental issues. No depression. No issue with sleep. No anxiety

ENDOCRINE: States she was diagnosed with prediabetes on her last annual exam. Denies cold

intolerance, dry skin, dry brittle hair texture. She denies increased thirst, denies increased

hunger, no increased urination, No menstral issues as she is menopausal.

HEMATOLOGIC/LYMPHATIC: No issue with bruising. No medical bleeding disorders. No

history of cancer.

ALLERGY/IMMUNOLOGY: No allergies. No HIV, No AIDS

OBJECTIVE

VITAL SIGNS: P:72 BP:104/62 RR: 16 T: 97.8 SpO2 RA: 99, Pain :0 /10

Ht :64 inches, Wt : 157 pounds, BMI: 26.9

General Appearance: J.J. is a pleasant, 70-year-old Caucasian female. She is articulate, speech is clear.

She is alert and oriented to person, place, time, and situation

PHYSICAL EXAM:

HEENT: Head is round with no lumps, bumps, or trauma noted. Hair distribution is even.
 5

PERRLA. Sclera is white, no discharge or excessive tearing noted. Bilateral ears with no

swelling, or erythema. No pain with manipulation of pinna or tragus. Bilateral canals clear

with no discharge. No cerumen noted. Bilateral T.M.s are pearly white. Cone of light noted at

5' oclock on the right and 7 o'clock on the left. Malleus noted bilaterally. yes are symmetrical,

no discharge noted, no edematous lymph nodes, mucous membranes pink and moist, unable to

visualize throat.

Head: Head is round with no lumps, bumps, or trauma noted. Hair distribution is even.

Eyes: PERRLA. Sclera is white, no discharge or excessive tearing noted. Red reflex present

bilaterally.

Ears: Bilateral ears with no swelling or erythema. No pain with manipulation of pinna or

tragus. Bilateral canals pink with no swelling or cerumen noted. Bilateral T.M.s are pearly

white. Cone of light noted at 5' oclock on the right and 7 o'clock on the left. Malleus noted

bilaterally.

Nose: nasal mucosa pink and moist. Inferior turbinates pink. Nares patent

bilaterally. Septum midline. No sinus pain upon palpation.

Mouth: mucus membranes moist and pink. Gums pink with no sores or lesions.

Tongue midline with no deviation, soft palate noted. Teeth are white with no

discoloration or caries noted. Bridge noted in upper front teeth and lower right posterior.

HEART: RRR, S1S2, no murmurs or extra beats noted

RESPIRATORY: lungs fields are clear in all fields, anteriorally

and posteriorally. No rales, rhonchi or wheezing noted

CHEST/BREASTS: chest expansion is symmetrical. Breast are symmetrical. No lymps or

 6

masses noted. No nipple discharge noted

GI: No pulsations or peristalsis notrd. Contour is slightly rounded. Bowel sounds are present

in all four quadrants. No masses or tenderness to palpation noted. There is an old healed

surgical scar noted in the right upper quadrant.

GU: labia intact and without rash, sores or lesions. Har distribution scant. No varicosities noted.

Vaginal walls are smooth and dull in color. Cervix is smooth with a greyish tinge. No adnexal

masses noted. No masses noted in the rectal vault. Stool is brown in color.

Neuro: speech is clear, good cognition, able to follow commands appropriately. Eyes:

PERRLA. Sclera is white, no discharge or excessive tearing noted. Red reflex present

bilaterally.

Lymph nodes: No swellin, tenderness noted in all nodes.

Musculosketal/Extremities: FROM noted in all joints. No decreased ROM noted.

Skin: Warm, dry and intact. Turgor is good. No lesions, rashes noted. Scattered moles noted

across the face and neck.

NEUROLOGIC: clear speech, good cognition, able to perform age-appropriate tasks

PSYCHIATRIC: The patient maintains good eye contact during conversation and has a bright,

positive affect.

ASSESSMENT:

1. Encounter for general adult medical examination with abnormal

findings Z00.01

2. Pre-diabetes R73.09
 7

3. Overweight E66.3

4. Encounter for screening for malignant neoplasm of colon Z12.11

(2021)

5. Encounter for screening for other suspected endocrine disorder Z13.29

(2021)

PLAN:

-Annual labs: CBC, CMP, Thyroid Panel, HgbA1-C, Lipid Panel, Vitamin D, UA,

-Refer for colonoscopy (2021)

-Exercise counseling

-Dietary counseling, refer patient to dietician to assist with meal planning for help with obesity

and pre- diabetes (Hayward & Selvin, 2022).

-Return to clinic in 2 weeks for f/u on results

References

Hayward, R., & Selvin, E. (2022, August). Screening for type 2 diabetes mellitus. UpToDate.

Retrieved February 19, 2023, from https://www.uptodate.com/contents/screening-for-type-

2-diabetes
 8

Home Page: United States Preventive Services Taskforce. Home page | United States Preventive

Services Taskforce. (2021, May). Retrieved February 19, 2023, from

https://www.uspreventiveservicestaskforce.org/uspstf