SHADOW HEALTH TINA JONES 28 YEAR OLD FEMALE
WEEK #9 COMPREHENSIVE SOAP NOTE 2025 UPDATED
, Great! Here's the complete set for Shadow Health Week #9: Tina
Jones, 28-Year-Old Female – NURS 6512 (2025)
History & HPI Summary
Patient: Tina Jones
Age: 28
Sex: Female
Ethnicity: African American
Setting: Outpatient primary care visit
Chief Complaint:
“I’m here for my annual physical exam.”
HPI Summary:
Tina is a 28-year-old female presenting for a routine physical. She
reports feeling generally well but seeks health maintenance and
prescription renewals. She has a history of asthma, type 2 diabetes,
hypertension, and obesity. She notes mild fatigue, poor dietary habits,
and occasional nonadherence to medications. No acute complaints like
chest pain, fever, or shortness of breath. Reports inconsistent exercise
and trouble controlling blood glucose.
Top Differential Diagnoses
Diagnosis Justification
Type 2 Diabetes History of DM2; elevated A1C; poor glycemic
Mellitus control
Hypertension On antihypertensive meds; BP mildly elevated
Obesity (BMI > 30) Sedentary lifestyle, poor diet, BMI > 30
WEEK #9 COMPREHENSIVE SOAP NOTE 2025 UPDATED
, Great! Here's the complete set for Shadow Health Week #9: Tina
Jones, 28-Year-Old Female – NURS 6512 (2025)
History & HPI Summary
Patient: Tina Jones
Age: 28
Sex: Female
Ethnicity: African American
Setting: Outpatient primary care visit
Chief Complaint:
“I’m here for my annual physical exam.”
HPI Summary:
Tina is a 28-year-old female presenting for a routine physical. She
reports feeling generally well but seeks health maintenance and
prescription renewals. She has a history of asthma, type 2 diabetes,
hypertension, and obesity. She notes mild fatigue, poor dietary habits,
and occasional nonadherence to medications. No acute complaints like
chest pain, fever, or shortness of breath. Reports inconsistent exercise
and trouble controlling blood glucose.
Top Differential Diagnoses
Diagnosis Justification
Type 2 Diabetes History of DM2; elevated A1C; poor glycemic
Mellitus control
Hypertension On antihypertensive meds; BP mildly elevated
Obesity (BMI > 30) Sedentary lifestyle, poor diet, BMI > 30
