final soap.docx - Review of Systems Personal/Social...

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S.O.A.P. Note Template CASE ID# Chief mplaintWhat brought you heretoday…(eg. headache)Patient states “I came in because I’m required to have a recent physical exam for the health insurance at my new job” History ofPresentIllnessChronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph formOnsetMs. Jones reports that she recently got employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 monthsago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Shehas no medication side eects at this time. She states that she fffeels healthy, is taking better care of herself than in the past, and islooking forward to beginning the new job.LocationDurationCharacterAggravating/associated factorsRelieving factorsTemporal factors –other things going onSeverityPastMedicalHistoryAdult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medicationsAdult illnesses: DM2 (diagnosed at 24); PCOS (diagnosed 2020); Asthma (diagnosed at 2.5 years of age); seasonal allergies; GERD; Near-sightednessImmunizations: tetanus booster (1 year ago); not current on FamilyHistoryInclude Parents, siblings; grandparents if applicable/known, cause of death, age, pertinent medical Mother (alive; age 50): high cholesterol, hypertensionFather (deceased at age 58): had HTN, DM2, elevated cholesterolCause of death: car accident 2.5 years agoPersonal/SocialHistoryEducation, marital status, occupation, alcohol/drug use, smoking status, sexualhistory if relevant, exercise, nutrition, religious preference if knownHigh School diploma at age 18Bachelor’s in Accounting: graduated a few months ago at age 28Alcohol use: alcohol consumption 1-2 times weekly, “a lot of time less than that. Maybe two or three times a month”Drug use: previous marijuana use from ages 15-20, last time Review of SystemsGeneral:Denies any recent or current illnesses.Denies fatigue, fever or chills. Admits weight loss (lost 10 pounds in the last four months r/t diet, exercise)Hair, Skin, & Nails:Admits acneAdmits some pigmentation changes around her neckDenies rash, pruritis, ecchymosesHead:Denies dizziness, headaches and loss of consciousnessNeck:Denies decreased ROM, neck pain or stiffnessAdmits to pigmentation changes on neck skin Eyes:Denies recent vision changesAdmits near sighted vision and began wearing glasses 3 months agoDenies for contact use

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