Virginia Jenkins NURS 7101 M50
Soap #2
SUBJECTIVE:
Chief Complaint: Wellness visit
History of Present Illness: Tina Jones is a 32-year-old African American female established
patient who presents to the clinic for her annual wellness visit. Pt. denies any changes in health
since her last visit. She denies pain.
If pt. had a CC involving pain OLDCARTS would be evaluated.
O: (onset) When did symptoms begin? Gradual or sudden?
L: (location) Can you point to where the pain is?
D: (duration) How long or how often?
C: (character) Can you describe the pain? Ex. Burning, gnawing, sharp, dull.
A: (aggravating/relieving factors) Is there anything that makes the pain better or worse?
R: (radiating) Does pain travel to other parts of the body?
T: (timing) Intermittent, Constant?
S: (severity) Can you rate your pain on a scale of 1-10? Do symptoms interfere with daily life?
Medications:
Albuterol inhaler prn
Lisinopril 20mg QD
Metformin 500mg Bid
Crestor 20 mg HS
Lo Loestrin Fe QD
Do you take your medications as prescribed?
Do you take any vitamins, herbs, home remedies, or OTC medicine?
When was the last time you used your inhaler?
Do you have any trouble getting or accessing your medications?
Allergies: Do you have any new allergies?
Past Medical History:
HTN, Type II Diabetes, Hyperlipidemia, Asthma
Family History: Any new diagnoses in your family of chronic disease or terminal illness?
Virginia Jenkins NURS 7101 M50
Personal & Social History
● Personal Status- graduate engineering student who works part-time as a barista on the
weekends
Have you visited the ER since your last visit? Have you been hospitalized or had surgery
since your last visit? Have you had any new diagnoses, immunizations, diagnostic tests or
screenings (last pelvic exam and PAP)?
● Social Relationships- Ask about: significant others, roommates, sexual partners, social
interactions with friends
● Diet/Nutrition- Ask about: food preferences, caffeine-containing beverages, changes in
appetite or weight, typical breakfast/lunch/dinner/snack.
● Functional Ability-Ask about: ability to perform self-care activities, ability to perform
skills needed for independent living.
● Mental Health: Ask about personal stress, sources of stress, feelings of depression,
anxiety, irritability, anger, thoughts of suicide.
● Tobacco, ETOH, Illicit Drug Use: Pt. drinks a couple of glasses of wine on weekends
to wind down from the week. Denies smoking or illicit drug use.
● Health Promotion-Exercise, stress management, sleep habits, routine exams, safety
practices.
● Environment-safety concerns, potential hazards at work or home
Review of Systems:
● Constitutional Health-fatigue, weakness, night sweats, unexplained weight changes,
fever, issues with sleep.
● HEENT- head, eyes, ears, nose, throat
Head – Headaches?
Ears – Any pain, cerumen, discharge, infection, decreased hearing, tinnitus?
Eyes – How is your visual acuity, changes in vision, blurriness, discharge?
Nose – Have you had any nasal discharge, epistaxis, sneezing, obstructions?
Throat – Have you had any mouth and oropharynx soreness, hoarseness, mouth or
tongue lesions, abscesses, ulcers, bleeding gums?
Neck – Do you have lymph node enlargement, edema, masses, pain, tenderness,
stiffness?
Virginia Jenkins NURS 7101 M50
● Respiratory System- Have you had cough productive/non-productive, hemoptysis,
frequent colds, wheezing, dyspnea, snoring?
● Cardiovascular System
Heart – Have you had palpitations, chest pain or tightness, dyspnea, orthopnea?
PV – Have you had coldness or warmth of extremities, numbness, edema,
varicose veins, pain at rest or with movement, changes in color?
● GI/GU
General Abdomen – Any pain, heartburn, N/V, dysphagia, hematemesis, jaundice,
ascites?
Elimination –Any change in bowel habits, pain or difficulty with defecation, gas,
bloating, changes in stool consistency or color, blood in stool,
diarrhea/constipation. Characteristics of urine, hesitancy, frequency, urges,
changes in urine stream.
● Reproductive System
Female Genitalia – presence of lesions, pain, discharge, odor, menstrual history
(date of onset, LMP, length of cycle, amenorrhea, dysmenorrhea, menorrhagia).
Sexual History – Have you had any new sexual relationships? What is the
orientation of your partner preference? How many partners have you had since
your last visit? Have you been using contraception, what kind, is it effective?
● Musculoskeletal
Muscles – Have you had twitching, cramping, weakness, pain?
Bones/Joints - Have you had joint edema or pain, redness, stiffness, deformity,
crepitus, ROM issues?
●Neurological
General – Have you had syncope, changes in LOC, seizures, cognitive changes
(confusion/memory loss)?
Gait – Have you had any loss of coordination, ataxia, paralysis, paresis, tremors?
Sensory – Have you had paresthesia, pain?
●Endocrine-Have you experienced any intolerances in heat or cold? Increased thirst,
changes in facial or body hair? Changes in skin? Unexplained weight change?
OBJECTIVE:
Vital Signs: BP 122/84, HR 76, Resp 16, Temp 98.6, O2Sats 99% on RA. She denies any pain.
Virginia Jenkins NURS 7101 M50
General Survey: Appearance, LOC & MMSE, height/weight, BMI, waist circumference
Assessment: Inspection, Palpation, Auscultation, Percussion. (Neck, Eyes, Ears, Skin,
Respiratory, Cardiovascular, Gastrointestinal, (Reproductive if pt. does not see a separate
provider for gynecological needs).
● Inspection
Skin – color, suspicious moles or skin lesions
Neck – symmetry, alignment of trachea, landmarks of triangles, suppleness,
masses, JVD distention
Eyes – check vision (visual acuity screen)
Ears – check hearing (Weber, Rinne, Whisper tests)
Throat – mouth and oropharynx soreness, hoarseness, mouth or tongue lesions,
abscesses, ulcers, bleeding gums?
Chest– movement for symmetry, use of accessory muscles
Heart - apical pulse, pulsations, heaves, lifts
Abdomen – masses, hernia, separation of muscles, contour, symmetry
Breast - Erythema, puckering, or peau d'orange, venous patterns, contour,
symmetry
Genitalia - lesions, pain, discharge, odor
● Palpation
Neck – trachea, thyroid, paravertebral muscles, lymph nodes
Chest – thoracic expansion, crepitus, vibrations, fremitus
Heart/PV – apical impulse, thrills, heaves, lifts, dorsalis pedis pulses, radial
pulses, temperature of extremities, edema
Abdomen – muscle resistance, tenderness, masses, bulges, liver, gallbladder,
spleen, kidneys, aortic pulsation
Breast – lymph nodes, masses, tenderness
Pelvic exam - -vaginal walls for smoothness, tenderness, lesions
-uterus for location, position, size, shape, contour, mobility, tenderness
-ovaries for size, shape, consistency, tenderness
-adnexal areas for masses and tenderness.
● Auscultation
Virginia Jenkins NURS 7101 M50
Chest – breath sounds, vocal resonance
Heart – carotid arteries (bruits), 5 cardiac areas, extra sounds, murmurs
Abdomen – bowel sounds, aortic, renal, iliac, femoral arteries (bruits)
● Percussion
Chest – tone, diaphragmatic excursion
Heart – estimate heart size
Abdomen – tone, liver borders, splenic dullness, gastric bubble
ASSESSMENT:
● Problem List 1.Asthma
2.HTN
3.DB II
4.HLD
● Labs/Diagnostics CBC- ensure adequate levels of blood and oxygen carrying capacity, evaluate immune
function.
CMP – Evaluate kidney, liver function, and electrolyte balances that may point to
underlying disease process or complication d/t medications.
Lipid profile – pt. has diagnosis of HLD. Lipid profile can help determine if medication
is effective.
PFTs – Monitor asthma, symptoms can vary over time.
A1C – Evaluate blood sugar level over past 3 months to determine level of control.
Vitamin D level- Pt. Has risk factor as AA of having deficient vit D levels that is a
known contributor to CVD and diabetes.
Pap smear (if not done in past 3 years per USPSTF) - some pts. Do not see a separate
doctor for these tests.
HCG – Pt. Is taking BC pills and is of childbearing age.
PHQ-2 if positive add PHQ-9 – annual screen recommended by USPSTF.
PLAN:
Administer any needed immunizations such as flu shot.
Educate Ms. Jones on continuing medications as prescribed pending lab results.
Virginia Jenkins NURS 7101 M50
Offer resources to obtain consistent medical care and access to medications if needed.
Educate pt. on the importance of healthy diet, exercise, STI prevention, asthma triggers, and
regular BS and BP checks.
Recommended screenings over the next 5 years: Annual pelvic/breast exam, annual depression
screen, Pap smear every 3 years, annual wellness exam with PCP.
Follow-ups: as needed.
References
Ball, Jane W., Dains, Joyce E., Flynn, John A., Solomon, Barry S., Stewart, Rosalyn W. (2019).
Seidel's guide to physical examination: An interprofessional approach (9th ed). Elsevier.
Johns Hopkins Medicine. Pulmonary function tests. Retrieved from
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/pulmonaryfunction-tests
Parva, N. R., Tadepalli, S., Singh, P., Qian, A., Joshi, R., Kandala, H., Nookala, V. K., &
Cheriyath, P. (2018). Prevalence of vitamin D deficiency and associated risk factors in
the US population (2011-2012). Cureus, 10(6), e2741.
https://doi.org/10.7759/cureus.2741
United States Preventive Services Task Force [USPSTF]. (2022). 2022 adult preventive health
guidelines: Ages 19 through 64 years. Retrieved from
https://content.highmarkprc.com/Files/Region/hbsneny/EducationManuals/PreventiveHea
lthGuidelines/neny-guidelines-2022-19to64.pdf