SOAP note: Annual Physical Examination Discussion

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SOAP note: Annual Physical Examination Discussion

Patient information

Patient initial: R.T. Age: 15.       Sex: female      Race: Caucasian

CC: Annual physical examination

HPI; R.T, a 15-year-old Caucasian female, showed up at the clinic unaccompanied for her routine physical. She declared that she had no medical conditions and that her most recent examination, which took place on May 6, 2021, had yielded typical tests and physical findings. She further claimed to perform BSE almost daily without noticing anomalous masses. Denies nausea, vomiting, and diarrhea SOAP note: Annual Physical Examination Discussion

Medication: none reported

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Allergy: NKFDA

PMH: no past medical/surgical history reported.

Immunization: up-to-date. Last received Tdap 5/7/2021

Family history: no significant family history was reported

Social history: The patient is her parents’ lone child. She is heterosexual, has a boyfriend, and has stated not using any contraceptives. She is currently in tenth grade. She lives with her mother in a safe neighborhood. Denies having ever smoked or used alcohol. Rarely exercise and wear a seat belt while driving. Eats a lot of fruits and veggies.

Reproductive history: Began menses at 12 years. LMP 5/7/2022. Follows a 28-day cycle. Nulliparous

ROS:

General : denies fever, chills, and changes in weight.

HEENT: no issue with vision or hearing is reported. SOAP note: Annual Physical Examination Discussion

CV: no chest pain or sudden changes in heartbeat

said.

G.I.: denies nausea, vomiting, and diarrhea.

GU: denies dysuria and polyuria

Msk: denies muscle pain and any other orthopedic injuries.

Skin and breast: deny skin rashes, bruising, lumps, or breast pain.

Neurological: denies cold or heat intolerances

O

PE:

Vts: T 37.1, HR 80, RR 20, BP 128/66, SpO2 100% Wt. 126 lb. Ht. 5’2 BMI 20.4

General: A&Ox3. Well-hydrated and appears stated age.

Skin: no rashes or bruises noted.

HEENT: normocephalic, EOMI. PERRLA. Nares patent bilaterally. No buccal nodules were noted. No JVD

CV: RRR, no murmur or galops

Msk: symmetrical with ROM intact.

Resp: no cyanosis. Clear lung sound.

Neurological: balanced gait. Speech clear.

Psychiatric: oriented to place and time. Good Insight and judgment (Jarvis et al.,2018).

A.

Encountered for a physical examination with no abnormal findings.

Due to her sexual history, she needs to be screened for STIs (Shafii et al.,2020).

Lab test and result

CBC: result pending

STD panel test: result pending

U.A.: result pending

P

Medication: no medication is recommended in her case.

Education: must be advised on the dangers of having unprotected sex. Be encouraged to take part in an exercise at least 3x a week. SOAP note: Annual Physical Examination Discussion

Follow-up: schedule the subsequent annual physical examination for 6/7/2023

 

 

 

References

Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.

Shafii, T., & Levine, D. (2020). Office-based screening for sexually transmitted infections in adolescents. Pediatrics, 145(Supplement_2), S219-S224. SOAP note: Annual Physical Examination Discussion