SOAP_NSG6020_LINA_CALDERON_7_PHYSICAL_EVALUATION - SOAP NOTE SPORTS PHYSICAL Name JM Date Age 14 Time 10:25 Sex Female SUBJECTIVE CC Mother states She

SOAP_NSG6020_LINA_CALDERON_7_PHYSICAL_EVALUATION - SOAP...

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SOAP NOTE SPORTS PHYSICAL Name: JM Date: 09/18/16 Time: 10:25 Age: 14 Sex: Female SUBJECTIVE CC: Mother states “She is here today for a sports physical for basketball” HPI: JM is a white non-Hispanic patient here today for her well child check-up. She is currently a Sophomore at School. JM appears healthy in non-acute distress, requesting sports physical evaluation for school. JM does well in school and belongs to high honor roll and plays basketball during winter and track during spring. Medications: MVI 1 tablet PO daily PMH Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas No past medical history, no surgeries, normal developmental millstones. No psychiatric history. No sexually active. All vaccines up to date. Last influenza vaccine was 09/01/16. Hospitalizations/Surgeries None Family History The patient lives at home with her mother and father she has a twin brother and they have no pets. All 4 grandparents are alive and without disease. Social History Patient and her family currently live in a condo in Sussex county NJ her parents and brother. She has never used alcohol, tobacco, or any illicit drugs. Denies anxiety or depression and is generally happy.
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ROS General Patient denies weight change, fatigue, fever, chills, night sweats, and energy level. Denies
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  • Fall '17
  • Ear canal, Rash, denies, white non-Hispanic patient, normal developmental millstones

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