Tina Jones Soap note

Tina Jones Soap note

History of Present Illness (HPI): The client T.J is a 28yo AA female. The client has visited the clinic for a complete medical examination, a requirement for securing a job vacancy as an accounting clerk. T.J denies recent acute issues. She reported PCOS that was diagnosed four months ago during the gynecological visit. She was given oral contraceptive drospirenone. No dental issues were diagnosed during the previous dental examination five months ago. However, the client reports that she was prescribed glasses three months ago during her last eye exam. She was then advised to attend follow-up clinics annually. She added that her primary care provider prescribed her metformin and daily inhaler for managing diabetes and asthma, respectively.


Current Medications:

  1. Metformin 850mg daily
  2. Flovent daily inhaler two puffs twice
  • Drospirenone 1 pill daily
  1. Albuterol (Proventil) Inhaler

Allergies: The client reports being on penicillin and cats. She denies latex allergy.

Past Medical History (PMH):

  1. PCOS
  2. Type II Diabetes
  • Asthma

Past Surgical History (PSH): The client denies previous surgical history

Sexual/Reproductive History: She denies being sexually active and uses daily oral pills as a contraceptive. The client reports being heterosexual.

Personal/Social History: Denies using tobacco products, heroin, cocaine, or other illegal products. Reports being a social drinker. She drinks a few bottles monthly when with friends. Reports using marijuana previously but stopped about six years ago. The client denies taking coffee.

Health Maintenance: The client checks her blood sugar every morning. She reports practicing sleep hygiene.

Personal/Social history: The client likes going out with her friends. She is an active church member. She enjoys watching documentaries. She obtained a bachelor’s degree in accounting recently. She has been walking and practicing healthy eating, resulting in weight loss.

Immunization History: She reports that all childhood immunizations are up to date. She reported receiving her last tetanus booster within the previous year. The client denies being immunized against seasonal flu.

Significant Family History: Her mother is 50 years and has been diagnosed with high blood pressure, high cholesterol, and obesity. Her father died of MVC at 58 years. He had a history of high blood pressure, diabetes mellitus, and high cholesterol.



General: Reports losing weight recently.

HEENT: Reports headaches that occur when studying. Reports using glasses. Denies hearing difficulty. Denies changes in taste or smell. Denies difficulty swallowing.

Cardiovascular/Peripheral Vascular: Denies dyspnea.

Respiratory: Denies shortness of breath.

Gastrointestinal: Denies constipation or abdominal pains.

Genitourinary: Denies consistency of urine. Reports being diagnosed with PCOS recently.

Musculoskeletal: Denies back pain.

Neurological: Denies numbness or muscle weakness.

Psychiatric: Denies insomnia, mood changes, or anxiety.



Physical Exam:

Vital signs: Temp 32.7C; BP 128/82; HR 78BPM; RR 16, SpO2 98% RA; Weight 84 kg; Height 170cm, and a BMI score of 29.

General: The client is well-nourished and smartly dressed. Additionally, she is appropriately dressed for today’s weather and her age. She seems to be in an appropriate affect and mood throughout the interview. She maintains eye-contact and upright posture during the clinical interview.

HEENT: No lesions noted on the head. No lesions on the eyelids. Moist and pink conjunctiva were noted. No tearing or drainage was noted. Good tongue movement noted.

Cardiovascular/Peripheral Vascular: Palpable peripheral pulses noted.

Respiratory: Regular breathing rate noted.

Gastrointestinal: No visible masses on the abdomen.

Musculoskeletal: Full range of motion detected.

Neurological: Alert and oriented to person, events, time, and situations.

Skin: Smooth skin with no pigmentation.

Gynecological/Rectal: Deferred by the client.



Differential Diagnoses

Potential diagnoses for this client include;

  1. PCOS
  2. Diabetes Mellitus
  • Asthma
  1. Overweight

PCOS: The first potential diagnosis for this client is PCOS. T. J revealed that she was diagnosed with this condition four months ago upon visiting her gynecologist. The gynecologist prescribed T.J drospirenone as a birth control method and treatment for PCOS. The medication improved her menstrual flow and cycle. However, her assessment results indicated some abnormalities, which should be monitored.

Diabetes Mellitus: The client was diagnosed with diabetes when she was 24. She manages her diabetes using Metformin 850mg daily and monitors her blood glucose daily. Her assessment results indicated several diabetes-related health complications, including peripheral neuropathy, diabetic retinopathy, and Acanthosis nigricans.

Asthma: T. J was diagnosed with this condition during childhood. She manages it using inhalers, including a Flovent daily inhaler, two puffs twice, and Albuterol (Proventil) Inhaler. However, the healthcare team should monitor her condition to prevent potential complications.

Overweight: The client’s last diagnosis is being overweight. Despite losing 6kg in the past few months following physical activities and a balanced diet, the client’s BMI score is 29, indicating she is overweight. The client should be encouraged to continue exercising and dieting to lose and maintain a healthy weight.


Please Use Info for Soap Note but rewrite info so that it does not show plagiarism once submitted

Week 9: Shadow Health DCE Comprehensive Physical Exam
Shannon Casey
Walden University
NURS-6512N-56-Advanced Health Assessment
Week 9: Shadow Health DCE Comprehensive Physical Exam
SUBJECTIVE DATA: Tina Jones, 28 years old, African American female
Reason for Visit: Pre-employment physical
History of Present Illness (HPI): Tina Jones is a 28-year-old African American female
who presents today for a complete head-to-toe pre-employment physical exam. She
recently gained employment as an accounting clerk at Smith, Stevens, Stewart, Silver &
Company where she begins in two weeks. She denies any acute concerns currently. She
has had regular check ups for her medical health including a gynecological visit four
months ago where she was diagnosed with PCOS and started on an oral contraceptive
drospirenone / ethinyl estradiol. At her dental exam five months ago she denies any
current dental problems. Her last eye exam was three months ago where she was given
prescription glasses to always wear and will follow up in one year. Her last physical
exam was five months ago where she was prescribed metformin for her diabetes, and a
daily inhaler for her asthma.
Medications: Metformin 850mg tabs daily for diabetes control, drospirenone/ethinyl
estradiol 1 pill daily for birth control/PCOS treatment, Flovent daily inhaler 2 puffs twice
a day, Albuterol (Proventil) Inhaler: 90mcg per spray, 2-3 sprays PRN for asthma
symptoms, Advil 200mg tabs, 3-4 tabs PRN for menstrual cramps
Allergies: Penicillin (rash, hives), Cats (sneezing, itchy eyes, asthma symptoms), Dust
(sneezing, wheezing, itchy eyes), no reported latex allergy.
Past Medical History (PMH): PCOS – diagnosed four months ago, Type II Diabetes –
diagnosed age 24, Asthma – childhood diagnosis age unknown.
Past Surgical History (PSH): No past surgical history
Sexual/Reproductive History: Heterosexual female, not currently sexually active.
Indicates new relationship that started about a month ago, with intention to become
sexually active. She is currently on birth control and indicates intention to use protective
STI contraceptive when needed. No known history of sexually transmitted infections. No
history of pregnancy.
Personal/Social History: No past or present tobacco use, reports drinking alcoholic
beverages (rum and coke) a “few times” per month with friends, indicating she is “not a
huge drinker”, use of alcohol started at age 15. Previously used marijuana but quit 6-7
years ago. Denies current use of marijuana, cocaine, heroin, or other illicit drugs. Patient
denies drinking coffee, and caffeine intake is limited to two diet cokes per day. TJ states
she checks her blood sugar once a day in the morning, with an average blood glucose of
90. She brushes her teeth twice daily and flosses a couple times per week, does not use
sunscreen, and indicates healthy sleeping patterns averaging 9 hours each night feeling
well rested in the morning. Patient enjoys going out with friends and recently started a
book club where they choose a book to read monthly and then get together to discuss it.
She is also an active member of her Baptist church with a strong relationship with God,
and enjoys watching science documentaries. She recently obtained her bachelor’s degree
in accounting. She has had a recent weight loss attributed to healthier eating and walking
for thirty to forty minutes four or five times a week, and swimming at the Y once a week.
TJ lives at home with her mother and sister, will be moving to an apartment in the city on
her own in about a month. She owns her own car and denies issues with transportation.
Denies financial concerns with her new employer, stating she will have full benefits.
Indicates recent dietary changes including reduction in carbohydrate intake, elimination
of sweets, increase use of whole grains, vegetables, and low-fat ingredients. A 24-hour
intake recount includes: smoothie with frozen bananas, strawberries, and yogurt – chicken
breast with broccoli, cauliflower, olive oil, garlic, and brown rice – black beans with
brown rice, and roasted butternut squash. Never married, no children.
Immunization History: Up to date on all childhood immunizations, last tetanus booster
about a year ago, denies seasonal flu vaccine.
Significant Family History: Mother: high cholesterol, high blood pressure, obesity, age
50. Father: high blood pressure, high cholesterol, diabetes, deceased at age 58 from
MVC. Brother: overweight. Sister: asthma. Uncle: alcoholism. Paternal Grandmother:
high blood pressure, cholesterol, age 82. Paternal Grandfather: high blood pressure,
diabetes, died from colon cancer. Maternal Grandmother: high blood pressure,
cholesterol, deceased at age 73 from stroke. Maternal Grandfather: high blood pressure,
cholesterol, died from heart attack.
Review of Systems:
General: Patient endorses recent weight loss, with vitals trend indicating 6 kg
weight loss. Denies fever, fatigue, chills, or night sweats. Denies difficulty
HEENT: Endorses history of headaches while studying, with none occurring in
recent history. Denies visual problems with improvement of vision since
obtaining prescription glasses. Denies issues with hearing, taste, or smell. Denies
sore throat, difficulty swallowing, or recent upper respiratory infections. Last
visual exam was three months ago. Denies history of eye pain, photophobia,
blurry vision, or drainage. Denies general HEENT issues.
Cardiovascular/Peripheral Vascular: Denies chest pain, palpitations, dyspnea
on exertion, edema, or other cardiovascular issues. No history of cardiovascular
studies. Recent blood pressure check at gynecologist office indicated normal
Respiratory: Denies dyspnea, cough, or shortness of breath. Denies recent upper
respiratory infections, mucous production, or hemoptysis. Uses daily inhaler with
improvement of asthma condition, indicates only having used rescue inhaler twice
in the past year. No known history of pneumonia or recent chest imaging.
Gastrointestinal: Denies abdominal pain, difficulty eating, constipation, nausea,
or vomiting. Reports of heartburn a few months ago with relief of symptoms
from prescribed Zantac – no recent issues and no longer taking medication.
Endorses regular bowel regimen with stool production once a day or every other
day with regular stool consistency and brown color. Denies use of stool softeners
or fiber supplements.
Genitourinary: Denies changes in frequency, color, or consistency of urine.
Denies dysuria or pain with urination. Indicates urine is yellow and clear. Denies
nocturia or history of sexually transmitted infections. Recently diagnosed with
PCOS and started on birth control. Indicates regular monthly periods, lasting five
days with medium flow, with last menses approximately two weeks ago. Recent
breast exam completed at doctor’s office, denies home breast exams.
Musculoskeletal: Denies recent musculoskeletal trauma, limitations in range of
motion, back pain, or joint pain. Denies use of assistive devices in ambulating.
Neurological: denies syncope, numbness, tingling, weakness, coordination, or
difficulty concentrating. Denies alterations in memory or recent/current
Psychiatric: Patient denies difficulty with sleeping, averaging 9 hours each night.
Pleasant mood and affect, without history of prolonged depression, and no current
concerns of stress, anxiety, or mood changes.
Physical Exam:
Vital signs: Height 170cm, weight 84 kg, BMI 29, BP 128/82 (97), HR 78BPM,
SpO2 99% RA, RR 15, Oral temperature 37.2 C.
General: Patient is dressed appropriately for age and weather and appears wellnourished. She sits comfortably throughout the exam and is interactive, with
appropriate mood and affect during questioning. Mannerisms are appropriate for
age and situation. Posture is upright and maintained. Hair is clean and well
HEENT: Head is normocephalic with no lesions noted or pain on palpation. No
dryness or dandruff visualized on scalp, hair appears well groomed with normal
texture and distribution, no balding noted. Facial features are symmetrical with
equal movement. Eyelids without lesions, ptosis, or edema. PERRLA +3,
conjunctiva is pink and moist, sclera is white, no drainage or tearing noted. Left
pupil with sharp disc margins, with mild retinal changes noted in the right eye.
EOMs are intact bilaterally, no nystagmus noted. Patient is tested for visual acuity
resulting in 20/20 vision in both eyes. Peripheral vision is intact in both eyes.
Bilateral nasal cavities patent with moist and pink mucosa, septum is midline.
Bilateral tympanic membranes intact and pearly gray with positive light reflex.
Patient passes hearing test bilaterally. Mucous membranes are pink and moist
without ulcers or sores noted. Tongue movement is good, with appropriate rise of
uvula and midline. Tonsils are +2 bilaterally. Dentition is in good condition, and
gag reflex is intact. No tenderness noted to bilateral frontal and maxillary sinuses.
Cardiovascular/Peripheral Vascular: Bilateral carotid pulses +2 without thrill.
PMI is palpated at the midclavicular line 5th intercostal space with no heaves or
lifts. Peripheral pulses are palpable in bilateral upper and lower extremities with
2+ amplitude. No bruit or thrill noted to bilateral carotid arteries, negative for
JVD. S1 and S2 sounds audible during auscultation with regular rate and rhythm,
no murmurs, gallops, or rubs. Bilateral renal, iliac, and femoral arteries without
bruit. Capillary refill < 3 seconds. No edema or varicosities noted.
Respiratory: Chest appears symmetric with regular rate and work of breathing,
no use of accessory muscles noted. Breath sounds are clear and present in all
lobes with no adventitious sounds noted. Bronchophony is muffled in all lobes.
No cough or sputum noted during exam. Spirometry: FVC 3.91L and FEV1/FVC
ratio of 80.56%. Normal fremitus is noted on palpation of anterior and posterior
chest wall. Percussion of anterior and posterior chest wall is resonant.
Gastrointestinal: Abdomen protuberant and symmetric with no visible masses or
lesions. Coarse hair growth is noted from pubis to umbilicus. Bowel sounds are
normoactive in all four quadrants. Aortic artery is without bruit. Abdomen is
tympanic on percussion. Liver span is 7 cm MCL on percussion, spleen is without
dullness. No CVA tenderness noted to bilateral flanks on percussion. Light and
deep palpation result in no tenderness, masses, guarding, or rebound to abdominal
quadrants. Liver is palpable 1 cm below right costal margin, and spleen and
bilateral kidneys are not palpable.
Musculoskeletal: Full range of motion of TMJ without crepitus. Bilateral upper
and lower extremities without swelling, masses or deformity. Full range of motion
noted to bilateral upper and lower extremities with 5/5 strength. Neck and hips
exhibit 5/5 strength.
Neurological: Alert and oriented to situation, self, date, and time. Cortical
function is intact. Decreased sensation is noted to bilateral great toes and forefoot.
Bilateral upper and lower extremities with positive sensation to light, sharp and
dull testing. Position sense intact to bilateral toes and fingers. Able to perform
smooth repetitive alternating movements in hands. Stereognosis is present. Deep
tendon reflexes 2+ in bilateral upper and lower extremities. Finger-to-nose
coordination is smooth bilaterally, and heel-to-shin coordination is smooth
bilaterally. Cranial nerves I-XII intact.
Skin: Skin is pink and warm without tenting. Stria noted to bilateral and medial
abdomen. Pustules present to bilateral cheeks. Acanthosis nigricans noted on
neck. Fingernails with no ridges or abnormalities, pink nailbeds.
No visible abnormalities noted, negative for jaundice, pallor, or cyanosis. Skin
turgor is within normal limits without tenting.
Gynecological/Rectal: patient deferred due to recent exam by gynecologist.
Diabetes: Although TJ is currently managing her diabetes with medication and consistent
daily blood glucose monitoring, her exam reveals multiple complications associated with
diabetes including peripheral neuropathy (indicated by her decreased sensation during
monofilament testing to bilateral feet), diabetic retinopathy (indicated by her mild retinal
changes in the right eye), and Acanthosis nigricans (indicated by the hyperpigmented
plaques on her neck) which is often characterized by insulin resistance and obesity.
PCOS: This recent diagnosis for TJ made by her gynecologist is being managed by her
newly prescribed birth control. Although she has had improvement in her menstrual
cycle and flow, there are still abnormalities in her assessment that should be monitored.
The abnormal hair on her face and abdomen are consistent with this diagnosis.
Asthma: This diagnosis is not new for TJ but is considered a chronic illness that should
continue to be monitored by her health care team. Newly prescribed daily inhalers
indicate that the condition is still current, and complications may arise if the patient does
not continue to properly manage her weight with nutrition and exercise.

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