Comprehensive (head-to-toe) physical assessment | Nursing homework help

1

Shadow Health Comprehensive SOAP Note Template

Name

Institution

This study source was downloaded by 100000784551390 from CourseHero.com on 10-21-2023 18:52:48 GMT -05:00

https://www.coursehero.com/file/195206814/Shadow-Health-Comprehensive-SOAP-Note-Templatedocx/

2

Patient Initials: __TJ_____ Age: ___28____ Gender: ____female___

SUBJECTIVE DATA

Chief Complaint (CC): “Pre-employment physical exam.”

History of Present Illness (HPI): The client, tina jones, presented herself to the hospital to find

a pre-employment meant for a new vacancy at Smith and Steve Company. The client fails to

accept her current health status mentioning that she is not sick. The previous diagnosis and

physical exam were performed four months ago, thus showing PCOS.

Medications: To control asthma, the doctor prescribes two puffs of Flovent and Proventil every

day. The patient is also advised to take 850mg of metformin to control diabetes, 600mg of

ibuprofen to control cramps, and Yaz for controlling PCOS.

Allergies: The patient has accounts of itchy eyes, dust-related breathing difficulties, and rashes

of penicillin.

Past Medical History (PMH): Accounts report that the patient was earlier diagnosed with

asthma at 21.5 years and diabetes at 24.

Past Surgical History (PSH): Denies previous records of surgeries.

Sexual/Reproductive History: The patient accounts that she is not in any relationship; she is

heterosexual. The client claims that she considers using a condom when she begins a new

relationship. In control of Yaz, the patient reports using PCOS.

Personal/Social History: As an accountant, the client accepts to be an alcoholic, although she

denies smoking or using illegal drugs.

This study source was downloaded by 100000784551390 from CourseHero.com on 10-21-2023 18:52:48 GMT -05:00

https://www.coursehero.com/file/195206814/Shadow-Health-Comprehensive-SOAP-Note-Templatedocx/

3

Health Maintenance: Tina Jones frequently visits the doctor for important check-ups, including

eye and dental check-ups. She also reports conducting exercises, controlling her diet, and taking

prescribed medication.

Immunization History: The client has the current vaccination record, being vaccinated against

tetanus two years ago.

Significant Family History: History. The client’s mother is 50-year-old with raised cholesterol

levels, while the father died of a car accident at 58. The client’s sister is asthmatic. Maternal

grandparents died of a stroke, with the grandmother dying at 73 and the grandfather at 78. The

paternal grandmother is alive, while the grandfather died at 56 because of colon cancer.

Review of Systems:

General: Accounts loss of weight to 10 pounds, denies of both general body weakness and

fever.

HEENT: Denies previous account of severe headaches. However, the patient accepts to

experience itchy eyes and double vision. Additionally, while around cats, the patient accepts to

experience sneezing. While swallowing, the patient denies of sore throat.

Respiratory: The client reports that she never experiences either breathing or coughing

challenges.

Cardiovascular/Peripheral Vascular: Denies palpitations.

Gastrointestinal: The client denies complications such as nausea, vomiting, or light stools.

Genitourinary: The client records that she never gets hurt while urinating.

Musculoskeletal: Never accepts of experience of painful muscles.

Neurological: Denies tingling.

This study source was downloaded by 100000784551390 from CourseHero.com on 10-21-2023 18:52:48 GMT -05:00

https://www.coursehero.com/file/195206814/Shadow-Health-Comprehensive-SOAP-Note-Templatedocx/

4

Psychiatric: The client never accepts to encounter stressful situations or suicidal thoughts.

Skin/hair/nails: Record facial acne and hairy legs.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Wt, 84 Kg, RR: 15, BP: 128 / 82, Ht: 170 cm,HR: 78,, Pulse Ox: 99% T: 99.0 F

General: The patient is well oriented; thus, she answers questions effectively.

HEENT: Normal record of both hair and scalp. The eyelids are also normal; however, the

conjunctiva is pinkish with no masses and white sclera. The mouth is recorded to be moist. There

are no records of goitre. PERRL is bilaterally normal

Neck: Thereof records of normal and no palpable neck.

Chest/Lungs: In all parts, the lungs sound clear, with normal expansion and bilateral equality in

the fremitus.

Heart/Peripheral Vascular: Presence of S1 and S2 with the absence of abnormal findings.

Genital/Rectal: Absence of either tenderness or masses.

Musculoskeletal: A strength of 5/5 in each muscle.

Neurological: Normality in Stereognosis and graphesthesia.

Skin: No abnormalities in the nails. Skin rashes.

Diagnostic results:

Pelvic exam and ultrasound indicated overgrown ovaries.

This study source was downloaded by 100000784551390 from CourseHero.com on 10-21-2023 18:52:48 GMT -05:00

https://www.coursehero.com/file/195206814/Shadow-Health-Comprehensive-SOAP-Note-Templatedocx/

5

ASSESSMENT:

#1. Polycystic ovary syndrome (PCOS). Includes overgrowth in the ovaries caused by excess

androgens (Kyrou et al., 2020). Signs of this kind of complication include hair growing on the

chin, irregular periods, and acne. The patient may therefore be suffering from this condition

because she experiences such signs.

#2. Diabetes. A chronic complication in which the pancreas fails to produce efficient insulin for

general body function. Causes of such conditions include an unhealthy diet, hence treated

through metformin (Johns et al., 218). The client may therefore have diabetes because she has

records of family accounts of diabetes. The client also reports taking metformin.

#3. Asthma. Asthma is a complication that results from allergens (Cockcroft, 2018). The patient

may have asthma because she reports dust allergies and taking Proventil, a cure for asthma.

#4. Obesity. A condition of having excess weight. There is evidence of being obese, although the

patient reports losing 10 pounds. The client records a high BMI, an indication that she is obese.

#5. Amenorrhea. This is the absence of a period for a long time (Fourman & Fazeli, 2015). It is

characterized by irregular periods. The patient reports having irregular periods.

References

This study source was downloaded by 100000784551390 from CourseHero.com on 10-21-2023 18:52:48 GMT -05:00

https://www.coursehero.com/file/195206814/Shadow-Health-Comprehensive-SOAP-Note-Templatedocx/

6

Cockcroft, D. W. (2018, February). Environmental causes of asthma. In Seminars in respiratory

and critical care medicine (Vol. 39, No. 01, pp. 012-018). Thieme Medical Publishers.

Fourman, L. T., & Fazeli, P. K. (2015). Neuroendocrine causes of amenorrhea—an update. The

Journal of Clinical Endocrinology & Metabolism, 100(3), 812-824.

Johns, E. C., Denison, F. C., Norman, J. E., & Reynolds, R. M. (2018). Gestational diabetes

mellitus: mechanisms, treatment, and complications. Trends in Endocrinology &

Metabolism, 29(11), 743-754.

Kyrou, I., Karteris, E., Robbins, T., Chatha, K., Drenos, F., & Randeva, H. S. (2020). Polycystic

ovary syndrome (PCOS) and COVID-19: an overlooked female patient population at

potentially higher risk during the COVID-19 pandemic. BMC Medicine, 18(1).

https://doi.org/10.1186/s12916-020-01697-5

This study source was downloaded by 100000784551390 from CourseHero.com on 10-21-2023 18:52:48 GMT -05:00

https://www.coursehero.com/file/195206814/Shadow-Health-Comprehensive-SOAP-Note-Templatedocx/
Powered by TCPDF (www.tcpdf.org)