10/11/23, 6:56 PM Tina Jones- Week 9 SH Comprehensive SOAP Note
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: TJ Age: 28 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC):
"I came in because I'm required to have a recent physical exam for the health insurance
at my new job."
History of Present Illness (HPI):
Presents for a general physical examination in preparation for her new position
as an accounting clerk at Smith, Stevens, Silver & Company. She denies having
any serious issues. She visited a gynecologist for a checkup four months prior,
during which a PCOS diagnosis was made, and a daily birth control regimen was
prescribed. She states that (Drospirenone/ethinyl estradiol) is taken consistently
every day with satisfactory symptom management. She had a physical
examination five months prior, during which she was prescribed Metformin for her
diabetes and a daily inhaler every day for her asthma. Her vision is now clearer,
and she no longer experiences migraines after seeing an eye doctor three
months ago. She claims that metformin, a healthy diet, and exercise are helping
her manage her diabetes. She routinely monitors her blood sugar levels each
day. The last time a rescue inhaler was used was three months ago with usage
reducing to twice yearly. The patient keeps a journal and measures her peak flow
at home.
Medications:
Metformin 850mg PO BID (last taken today)
Flovent 110mcg/spray 2 puffs BID (last taken today)
Proventil 90mcg/spray 2 puffs PRN for wheezing and shortness of breath (last
used 3months ago)
Drospirenone/Ethinyl Estradiol Birth Control 1 tablet PO daily (last taken today)
Allergies:
Penicillin: causes a rash.
Denies food allergies.
Denies latex allergy.
© 2021 Walden University, LLC Page 1 of 6
Environmental allergies to cats and dust that cause runny nose, itchy and
swollen eyes, and increased asthma symptoms.
Past Medical History (PMH):
At the age of two and a half, asthma was discovered. When she is around
cats, she utilizes her albuterol inhaler. Three months ago, she had her
most recent asthma attack which she was able to treat with her inhaler
about:blank 1/6
, 10/11/23, 6:56 PM Tina Jones- Week 9 SH Comprehensive SOAP Note
© 2021 Walden University, LLC Page 1 of 6
Environmental allergies to cats and dust that cause runny nose, itchy and
swollen eyes, and increased asthma symptoms.
Past Medical History (PMH):
At the age of two and a half, asthma was discovered. When she is around
cats, she utilizes her albuterol inhaler. Three months ago, she had her
most recent asthma attack, which she was able to treat with her inhaler.
She last spent time in the hospital for asthma in high school. Never
intubated.
Type 2 diabetes, identified at 24 years old. She started taking metformin
five months ago, and at first, she experienced some gastrointestinal
adverse effects, but they have since subsided after discovering that eating
yogurt can help with side effects.
She has a history of hypertension, which was brought under control when
she started a diet and exercise regimen, and she measures her blood
sugar once a day in the morning, with average readings being around 90.
It was discovered that she had PCOS and was diagnosed four months
ago. She was put on birth control, and her periods have stabilized with
less side effects.
Past Surgical History (PSH):
No surgeries
Sexual/Reproductive History:
Menarche at age 11.
First sexual encounter at age 18.
Heterosexual: new boyfriend, not sexually active but plan to be, will use
condoms.
Gravida 0; Para 0.
Last menstrual period 2 weeks ago; Diagnosed with PCOS four months
ago. For the past four months (after initiating birth control) cycles regular
(every 4 weeks) with moderate bleeding lasting 5 days.
Last Pap smear was 4 months ago during visit with gynecologist
Personal/Social History:
Never married
No children
© 2021 Walden University, LLC Page 2 of 6
Currently lives with mother but will move into own apartment in one month.
Begins her new position in two weeks at Smith, Stevens, Stewart, Silver, &
Company.
Has smoke detectors at home,
Enjoys hanging out with friends, attending book club (reading), attending Bible
study, and volunteering in her church.
Strong family and social support system. She explains that family and church
help her cope with stress.
No tobacco use
about:blank 2/6
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: TJ Age: 28 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC):
"I came in because I'm required to have a recent physical exam for the health insurance
at my new job."
History of Present Illness (HPI):
Presents for a general physical examination in preparation for her new position
as an accounting clerk at Smith, Stevens, Silver & Company. She denies having
any serious issues. She visited a gynecologist for a checkup four months prior,
during which a PCOS diagnosis was made, and a daily birth control regimen was
prescribed. She states that (Drospirenone/ethinyl estradiol) is taken consistently
every day with satisfactory symptom management. She had a physical
examination five months prior, during which she was prescribed Metformin for her
diabetes and a daily inhaler every day for her asthma. Her vision is now clearer,
and she no longer experiences migraines after seeing an eye doctor three
months ago. She claims that metformin, a healthy diet, and exercise are helping
her manage her diabetes. She routinely monitors her blood sugar levels each
day. The last time a rescue inhaler was used was three months ago with usage
reducing to twice yearly. The patient keeps a journal and measures her peak flow
at home.
Medications:
Metformin 850mg PO BID (last taken today)
Flovent 110mcg/spray 2 puffs BID (last taken today)
Proventil 90mcg/spray 2 puffs PRN for wheezing and shortness of breath (last
used 3months ago)
Drospirenone/Ethinyl Estradiol Birth Control 1 tablet PO daily (last taken today)
Allergies:
Penicillin: causes a rash.
Denies food allergies.
Denies latex allergy.
© 2021 Walden University, LLC Page 1 of 6
Environmental allergies to cats and dust that cause runny nose, itchy and
swollen eyes, and increased asthma symptoms.
Past Medical History (PMH):
At the age of two and a half, asthma was discovered. When she is around
cats, she utilizes her albuterol inhaler. Three months ago, she had her
most recent asthma attack which she was able to treat with her inhaler
about:blank 1/6
, 10/11/23, 6:56 PM Tina Jones- Week 9 SH Comprehensive SOAP Note
© 2021 Walden University, LLC Page 1 of 6
Environmental allergies to cats and dust that cause runny nose, itchy and
swollen eyes, and increased asthma symptoms.
Past Medical History (PMH):
At the age of two and a half, asthma was discovered. When she is around
cats, she utilizes her albuterol inhaler. Three months ago, she had her
most recent asthma attack, which she was able to treat with her inhaler.
She last spent time in the hospital for asthma in high school. Never
intubated.
Type 2 diabetes, identified at 24 years old. She started taking metformin
five months ago, and at first, she experienced some gastrointestinal
adverse effects, but they have since subsided after discovering that eating
yogurt can help with side effects.
She has a history of hypertension, which was brought under control when
she started a diet and exercise regimen, and she measures her blood
sugar once a day in the morning, with average readings being around 90.
It was discovered that she had PCOS and was diagnosed four months
ago. She was put on birth control, and her periods have stabilized with
less side effects.
Past Surgical History (PSH):
No surgeries
Sexual/Reproductive History:
Menarche at age 11.
First sexual encounter at age 18.
Heterosexual: new boyfriend, not sexually active but plan to be, will use
condoms.
Gravida 0; Para 0.
Last menstrual period 2 weeks ago; Diagnosed with PCOS four months
ago. For the past four months (after initiating birth control) cycles regular
(every 4 weeks) with moderate bleeding lasting 5 days.
Last Pap smear was 4 months ago during visit with gynecologist
Personal/Social History:
Never married
No children
© 2021 Walden University, LLC Page 2 of 6
Currently lives with mother but will move into own apartment in one month.
Begins her new position in two weeks at Smith, Stevens, Stewart, Silver, &
Company.
Has smoke detectors at home,
Enjoys hanging out with friends, attending book club (reading), attending Bible
study, and volunteering in her church.
Strong family and social support system. She explains that family and church
help her cope with stress.
No tobacco use
about:blank 2/6
