SOAP: Wellness visit
**
William Paterson University
NUR 6041-816: Advanced Nursing Practicum I
**
October 7th, 2025
, 2
SUBJECTIVE
CC: “I haven’t been to the doctor in years, so I am here for my annual physical exam.”
HPI: A.C. is a 47-year-old female who presents today for an annual physical exam.
Reports no past medical history but reports family history: Mom has type 2 diabetes, and
Dad had a CVA at age 72 and expired. She has not been to a doctor in approximately
nine years and states, “I am Dominican, so unless I feel sick, I don’t need to go to the
doctor.” The last encounter with a doctor was when she was hospitalized for her cesarean
section in 2016. She is not up to date on her preventive screening and would like to do so
as she is now getting older. Reports no complaints at this time; overall, she states she is
feeling well. Reports last menstrual period was 11 months ago. Reports no history of
fractures, injuries, or trauma. She denies fever, fatigue, chest pain, hot flashes, night
sweats, dizziness, palpitations, shortness of breath, gastrointestinal problems, and urinary
problems.
PMH: No past medical history. No recent hospitalizations or blood transfusions.
PSH: Cesarean Section 2016
Family History:
Mother: age 70, living, hx of DM2
Father: CVA and expired age 72
, 3
Social History:
A.C. is currently separated from her significant other. She lives in a house with her
mother and only child (age 9). The house has smoke detectors, carbon monoxide
detectors, and no pets. She reports completing some college but no degree. She is
currently employed full-time as a receptionist at a law firm and reports no occupational
health risks. She wears a seatbelt when in the car and wears sunscreen when outdoors.
She has health insurance and is able to afford her groceries and bills. She feels supported
by her mother. She is currently not sexually active. Had a total of 1 pregnancy at age 38
(G1P1001), no complications. Patient is in perimenopause; reports last menstrual period
was 11 months ago. Last pap smear was 8 years ago and normal. Last mammogram was 5
years ago and normal. Patient’s diet is low in fiber, low in protein, and high in
carbohydrates. Patient reports breakfast is fruits and cheese or a bagel, reports needing a
snack between such as fruit, lunch is a ham and cheese sandwich, and dinner is chicken,
green banana, rice, and beans. Snacks include fruits, olives, cheese, and crackers. Denies
fast food and vegetables. Reports drinking a ginger ale nightly and drinks Snapples
during the day. Drinks 1 cup of coffee daily with 1.5 tablespoons of sugar. Reports
drinking 2-3 bottles of water daily. Patient demonstrates a knowledge deficit related to
nutrition and dietary management. Denies smoking and illicit drug use. Reports drinking
alcohol occasionally, 1 glass of red wine; last drink was in August. Patient does not
exercise on a regular basis. Reports getting 7 hours of sleep. Denies recent traveling.
Denies feeling depressed, empty, loss of interest, loss of energy, and suicidal thoughts.
**
William Paterson University
NUR 6041-816: Advanced Nursing Practicum I
**
October 7th, 2025
, 2
SUBJECTIVE
CC: “I haven’t been to the doctor in years, so I am here for my annual physical exam.”
HPI: A.C. is a 47-year-old female who presents today for an annual physical exam.
Reports no past medical history but reports family history: Mom has type 2 diabetes, and
Dad had a CVA at age 72 and expired. She has not been to a doctor in approximately
nine years and states, “I am Dominican, so unless I feel sick, I don’t need to go to the
doctor.” The last encounter with a doctor was when she was hospitalized for her cesarean
section in 2016. She is not up to date on her preventive screening and would like to do so
as she is now getting older. Reports no complaints at this time; overall, she states she is
feeling well. Reports last menstrual period was 11 months ago. Reports no history of
fractures, injuries, or trauma. She denies fever, fatigue, chest pain, hot flashes, night
sweats, dizziness, palpitations, shortness of breath, gastrointestinal problems, and urinary
problems.
PMH: No past medical history. No recent hospitalizations or blood transfusions.
PSH: Cesarean Section 2016
Family History:
Mother: age 70, living, hx of DM2
Father: CVA and expired age 72
, 3
Social History:
A.C. is currently separated from her significant other. She lives in a house with her
mother and only child (age 9). The house has smoke detectors, carbon monoxide
detectors, and no pets. She reports completing some college but no degree. She is
currently employed full-time as a receptionist at a law firm and reports no occupational
health risks. She wears a seatbelt when in the car and wears sunscreen when outdoors.
She has health insurance and is able to afford her groceries and bills. She feels supported
by her mother. She is currently not sexually active. Had a total of 1 pregnancy at age 38
(G1P1001), no complications. Patient is in perimenopause; reports last menstrual period
was 11 months ago. Last pap smear was 8 years ago and normal. Last mammogram was 5
years ago and normal. Patient’s diet is low in fiber, low in protein, and high in
carbohydrates. Patient reports breakfast is fruits and cheese or a bagel, reports needing a
snack between such as fruit, lunch is a ham and cheese sandwich, and dinner is chicken,
green banana, rice, and beans. Snacks include fruits, olives, cheese, and crackers. Denies
fast food and vegetables. Reports drinking a ginger ale nightly and drinks Snapples
during the day. Drinks 1 cup of coffee daily with 1.5 tablespoons of sugar. Reports
drinking 2-3 bottles of water daily. Patient demonstrates a knowledge deficit related to
nutrition and dietary management. Denies smoking and illicit drug use. Reports drinking
alcohol occasionally, 1 glass of red wine; last drink was in August. Patient does not
exercise on a regular basis. Reports getting 7 hours of sleep. Denies recent traveling.
Denies feeling depressed, empty, loss of interest, loss of energy, and suicidal thoughts.
