Week 9:

Shadow Health Comprehensive SOAP Note Documentation with Tina Jones

Walden University

NURS 6512N-38: Advanced Health Assessment and Diagnostic Reasoning

Dr. Charleen Singh

June 26th , 2023

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Patient information:
 Patient Initials: T.J.
 Age: 28
 Gender: Female
 Race: African American
 Height: 5ft 7in
 Weight: 90kg

SUBJECTIVE DATA:

 Chief Complaint (CC): needs a “recent physical exam for the health insurance” at her new
job.

 History of Present Illness (HPI): Ms. Tina Jones presents today for a general physical
examination for her new position as an accounting clerk for Smith, Stevens, Stewart, Silver
and Company as an accounting clerk starting in 2 weeks. She states that she will be
receiving full benefits with her new job. She denies having any serious issues at this time.
Patient reports she had two doctor’s visits earlier this year at this clinic. One of the doctor’s
visits was regarding a checkup due to not feeling well and a diabetic ulcer and she was
prescribed Metformin and daily blood glucose checks for her type 2 diabetes. Since that
visit, she states that her diabetes has been more controlled, and she feels that she is in better
shape and has been eating healthier. She reports that she routinely monitors blood glucose
levels every morning. A few weeks ago, the patient reported seeing a gynecologist at this
clinic and a pap smear was performed and she was diagnosed with polycystic ovarian
syndrome (PCOS) and prescribed birth control as her daily regimen. The birth control that
was prescribed was Drospirenone/ethinyl estradiol and she has been consistently taking the
medication every day and has been having satisfactory symptom management such as she
gets her period every month since starting birth control and her menstrual has been lasting
5 days and her bleeding is not excessive. She also uses her daily inhaler, Flovent, to
manage her asthma. She reports has not used her rescue inhaler, Albuterol, in 3 months.
Her last eye exam was 3 months ago, and she was prescribed glasses. Her last dental exam
was 5 months ago.

 Medications:
o Flovent 110mcg/spray 2 puffs BID – daily inhaler (last dose: this morning)
o Drospirenone/ethinyl estradiol 1 tablet PO daily – birth control/treating POCS (last
dose: with breakfast this morning)
o Metformin 850mg PO BID (last dose: this morning)
o Albuterol inhaler two puffs per day and as needed (does not use anymore and it has
been 3 months since she used it)
o Ibuprofen (Advil) 600mg po as needed for menstrual cramps/pain (last dose: 6 weeks
ago)
o Denies taking vitamins and supplements.

 Allergies:

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 o cats (reaction: increased asthma symptoms, runny nose, itchy and swollen eyes)
o penicillin (reaction: rash) – last reaction was when she was younger.
o denies allergies to latex and food allergies.

 Past Medical History (PMH): type 2 diabetes (diagnosed at 24 years old) , asthma
(diagnosed at 2.5 years old) and last asthma attack was in high school, polycystic ovarian
syndrome , diabetic ulcers, previous marijuana smoker (states she stopped), back pain,
hypertension (currently not on meds; diet controlled), GERD and hypertension. Has
never been intubated.

 Past Surgical History (PSH): denies prior past surgeries.

 Sexual/Reproductive History: Menarche started at the age of 11 years old. Her first
sexual encounter was at age 18. Patient reports that she is heterosexual and has a new
boyfriend but has not been sexually active yet with him but plans to do so. She plans to
use condoms with her new partner. Gravida: 0. Para: 0. Her last menstrual period was 2
weeks ago, and it lasted for 5 days and the patient states that the bleeding was not
excessive. Last GYN visit was 4 months ago, and her STD panel was negative. During
this GYN visit, pap smear was performed, and she was diagnosed with PCOS and has
been on birth control and menstrual cycles have been regular and every 4 weeks. Period
cramps have improved since birth control was started.

 Personal/Social History: She has never been married. Has no children. Patient’s highest
level of education is a Bachelor of Arts in Accounting, and she obtained her degree a few
months ago. Her new job since graduation will be with Smith, Stevens, Stewart, Silver,
and Company as an accounting clerk starting in 2 weeks. She currently lives with mother
and sister and plans to move out in about a month in single family home. Patient reports
that she uses church as a coping mechanism when going through stress. Her religion is
Baptist and believes her faith is a big part of her life. She is very active in church and
believes she has a strong family and support system. She has friends and a boyfriend that
she enjoys hanging out with. Her hobbies include: book club with her friends, bible study
at church and watching TV alone. She enjoys science documentaries. No recent foreign
travel. She has her own car and expresses that access to healthcare is not an issue for her.
She reports that she drinks alcohol a couple times a month and goes out on the weekends
and has a few drinks with friends. She shares that she used to smoke marijuana from age
15 to 21 but does not smoke anymore. Denies other illicit drug use currently and in the
past. Denies current feeling of depression, anxiety, and thoughts of suicide.

 Health Maintenance: Patient shares that she has been eating “healthier” and tries to not
have more than 2 diet cokes a day. Does not drink coffee. States that she eats less carbs,
does not eat sweets anymore. She now eats whole grains and low-fat food options. She
has found ways to prepare vegetables that she likes. Patient states that she has been
limiting caffeine intake. Last asthma attack was 3 months ago and has been using daily
inhaler and her asthma has been resolved since. She reports that checks her blood glucose
every morning and tries to check it around the same time each morning. Has a glucometer
at home, it usually around ranges around 90. Patient has a history of hypertension but has

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 improved with diet changes and exercise and has never been on BP medications. Patient
exercises more often by walking for 30-40 mins for 4-5 times a week and goes swimming
at the YMCA with her friend Selena once a week. Her last eye exam was 3 months ago
and was prescribed glasses. Dental exam was 5 months ago and patient reports no
abnormalities were found. Patient states she gets 8-9 hours of sleep. Wears seatbelts
when driving and present in any motor vehicle. She uses sunscreen. Patient shares that as
a diabetic, she feels that her diabetes is in control and that she is in better shape and
eating healthier and less stressed. Her last 2 doctor’s appointments were earlier this year.
One checkup was regarding her diabetes, and she was prescribed metformin and then few
later, gynecologist did a pap smear and diagnosed with PCOS.

 Immunization History:
o Patient states that she is up to date with childhood immunizations.
o Tetanus booster – a year ago (2022)
o Has not received the flu shot from this past flu season.
o PPD – negative (2 years ago)
o HPV – not received.
o Meningococcal vaccine was received at 19 years old.
 Significant Family History:
o Mother: 50 years old, history of high cholesterol and high blood pressure
o Father: deceased at 58 years old (2022) due to car accident, history of high blood
pressure and diabetes
o Sister: 15 years old with a history of asthma
o Brother: 25 years old with a history of obesity
o Maternal grandmother: deceased at 73 years old due to a stroke (2018), history
of high blood pressure and high cholesterol.
o Maternal grandfather: deceased at 80 years old, history of high blood pressure
and high cholesterol.
o Paternal grandmother: 82 years old, alive, history of high blood pressure and
high cholesterol
o Paternal grandfather: deceased at 65 years old.

Review of Systems:
 General: Tina Jones is a 28-year-old, African American female who reports decreased
stress and denies current feelings of fatigue, anxiety, depression, and thoughts of suicide.
Speech is fluent, clear and she speaks in full sentences and follows commands. Patient is
calm, cooperative, and pleasant. Patient makes direct eye contact with communication.
Good historian.

 HEENT: Head: denies recent headaches, dizziness, migraines, seizures, and head injury.
Eyes: denies eye pain, eye discharge, eye discomfort, or itching. Denies exposure to
allergies recently. Currently wears corrective lenses to help with headaches and blurry
vision. Ears: no ear pain or hearing changes. Nose: denies changes to nose. runny nose
when around cats. denies difficulty with smelling. Neck: denies neck injury, pain or
trauma. Mouth/Throat: denies chewing nor swallowing difficulties. denies changes to

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 teeth or gums. denies changes to voice and taste. No report of dry mouth. She has no
dental appliances. last dental checkup was 5 months ago.
 Respiratory: patient denies shortness of breath at rest, activity, ambulation, and
orthopnea. Reports no current respiratory distress or issues. denies history of pneumonia.
denies hemoptysis. no history of TB. Denies any recent respiratory illnesses.

 Cardiovascular/Peripheral Vascular: denies chest pain, palpitations, or heart murmurs.

denies swelling to the legs. Has a history of hypertension and has never been on BP
medications and has improved her hypertension with her diet and exercise. Denies history
of heart attack. no history of EKG.

 Gastrointestinal: denies nausea, vomiting, or abdominal pain. reports normal bowel

pattern. denies hematemesis nor blood in stool. Denies hemorrhoids.

 Genitourinary: denies polyuria and nocturia. Denies dysuria and hematuria. Menstrual is
regular and bleeding is no longer excessive since starting on birth control to treat PCOS.
Denies breast changes. Denies breast cancer history in the family.

 Musculoskeletal: denies muscle weakness, pain and joint stiffness. Denies history of
arthritis or gout. No history of trauma or fractures. Full ROM x4 extremities. Full
sensation to touch. Steady gait.

 Neurological: denies any numbness, tingling, syncope episodes, seizures, dizziness,

headaches, or change in bowel/bladder control. Denies tremors. Denies history of
stroke/TIAs.

 Psychiatric: denies history of anxiety and depression. Last time she was feeling
depressed was a year ago when her father passed away. Her depression lasted a month,
and it was a part of her grieving process. Denies history of anxiety. Sleeps at least 8 hours
a day. Denies suicidal or homicidal history. She states she no longer feels stressed as she
did in her last visit (week 4 in this course). She is excited about starting her new job as an
accounting at this new company.

 Skin/hair/nails: patient has facial acne and states that birth control is helping to
improve her acne. Pt reports hyperpigmentation on neck. Denies other skin changes.
Denies changes to moles and denies rashes. Denies abnormal bruising.

OBJECTIVE DATA:

Physical Exam:
 Vital signs: 128/82, MAP: 97.3, HR 78, RR 15, 37.2 C oral, and oxygen saturation
@99% room air. Height: 5ft 7in. Weight: 90kg. BMI: 31.
 General: Ms. Jones is a calm, cooperative, pleasant, 28-year-old African American
single woman who presents to the clinic. She is the primary source of the history. She
communicates with clear and complete full sentences and makes eye contact throughout
the interview. Speech is clear and coherent. Patient is AAOX4, and in no apparent

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 distress. She is well-nourish, age appropriate with good hygiene and kempt appearance.
She is a good historian and answer questions appropriately.

HEENT:
Neck:
Chest/Lungs: performed spirometry: FVC: 1.78 and FEVc: 1.549.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:

Diagnostic results:

ASSESSMENT:

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be
required for future courses.

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