2
SOAP Note: Comprehensive Physical
Subjective
CC: “I am here for my physical today.”
HPI: This patient is a 74-year-old female that presents to the office today for her yearly
Medicare wellness exam. The patient has multiple chronic conditions according to the patient’s
report.
Social History:
The patient lives in a single-story home with handrails at the steps. She is married and has 2
adult children. The patient’s daughter and son will come by and visit at least 3 times per week
and help with taking the trash out, laundry, and assisting her with picking up groceries. The
patient is retired from being a bank teller for more than 40 years. The patient reports she has
never smoked and denies any other forms of nicotine. The patient denies any alcohol usage or
illicit drugs. However, she does drink a moderate amount of caffeine daily. The patient reports
being able to perform all ADL’s independently, she reports her children come to help her without
being asked for help. Patient denies having difficulty seeing, hearing, concentrating,
remembering or making decisions. She can climb stairs, run errands and dress herself without
difficulty or assistance. Patient reports her right hand is her dominant hand. Patient denies having
smoke detectors or carbon monoxide detectors in her home- I gave her information on the local
fire department will install those for free. Patient reports feeling restless and anxious to some
extent, it is affecting her sleep. The patient reports she is sexually active and monogamous. She
does have an advance directive, power of attorney, will accept blood in case of an emergency
and is a full code. Patient admit to regular exercise with no dietary restrictions.
Family History: Father- essential hypertension died at 67, Mother- essential hypertension,
hyperlipidemia, malignant tumor of breast, disorder of thyroid gland, died at 92, paternal
grandmother- essential hypertension, and arthritis, died at 72, maternal grandfather-
hyperlipidemia, coronary arteriosclerosis, died at 62, maternal grandmother- malignant neoplasm
of uterus, died at 58.
Surgical History: Cholecystectomy on 07/16/2018.
Hospitalizations: Denies any hospitalizations other than when she gave vaginal birth to her
children.
PMH: Hypothyroidism, perennial allergic rhinitis, heterozygous methylenetetrahydrofolate
reductase mutation, generalized anxiety disorder, gastroesophageal reflux disease, erosive
osteoarthritis, osteopenia, and mixed hyperlipidemia.
Allergies: Amoxicillin (itching, mild reaction) (rash, mild), Bactrim (itching, mild), Cefdinir
(itching, mild), Keflex (itching, mild) (rash, mild), Levaquin (unknown reaction)
, 3
Medications:
- Cetirizine 10mg tablet PO BID for allergic rhinitis
- Atorvastatin 20mg tablet PO daily for hyperlipidemia
- Azelastine 137mcg nasal spray aerosol, instill 2 sprays per nostril for allergic rhinitis.
- Biotin 1mg tablet PO daily for B vitamin supplement
- Cholecalciferol 50mcg tablet PO daily for vitamin D3 supplement for Osteopenia.
- Fish Oil 1000mg capsule PO daily to help reduce pain and swelling in joints.
- Fluticasone Propionate 50mcg/nasal spray for allergic rhinitis.
- L- Methylfolate 15mg tablet PO daily to help reduce anxiety.
- Synthroid 25mcg tablet PO daily for hypothyroidism
- Vitamin C 1000mg tablet PO daily for Osteopenia.
- Voltaren 1% topical gel apply 2 grams to the affected area by topical route every 6 hours
as needed per day for joint pain- Erosive Osteoarthritis.
Environmental Factors/Immunizations/Health Prevention: Last pap smear was 08/15/2021
with normal results. Patient has never had an abnormal pap smear. Denies ever having the HPV
vaccine. Age of menopause was 55. Age of first child was 24. Had Moderna Covid-19
vaccination x2 on 2/23/21 and 3/23/21 with a booster on 1/14/22. Most recent Tdap vaccine was
05/24/23. Influenza vaccine was on 10/23/23. Last Pneumococcal vaccine was 11/14/17 and
patient agrees to received one today. Zoster two shot series is up to date (07/29/22 and 11/17/22).
The patient’s last mammogram was 1/10/23 and has one scheduled for after the first of the year.
Patients last colonoscopy was 07/16/18 with normal results. Patient has denied scheduling a
colonoscopy at this time. Dental exam every 6 months. Last eye exam was 09/12/23. Hearing
screen 11/2022, normal results. DEXA scan 1/10/23 which showed Osteopenia of the lumbar
spine and left femoral neck.
ROS
Constitutional: The patient reports occasional fatigue but denies fever, chills, or unintentional
weight loss.
Skin: Reports changes in skin texture, occasional dryness, and a few age spots. No history of
skin cancers or significant rashes.
HEENT: Reports occasional dry eyes and mild vision changes. No history of eye infections or
significant hearing loss. Occasional seasonal allergies, managed with OTC medications.
No history of frequent headaches or head injuries. Denies dizziness or vertigo. No issues with
taste or smell.
Cardiovascular: Denies chest pain, palpitations, or shortness of breath. Reports occasional mild
swelling in ankles after prolonged standing.
Respiratory: Denies chronic cough, wheezing, or shortness of breath. No history of chronic
respiratory conditions.
Abdominal/GI: Reports occasional indigestion and constipation. No significant abdominal pain,
nausea, or vomiting. No history of GI bleeding.
SOAP Note: Comprehensive Physical
Subjective
CC: “I am here for my physical today.”
HPI: This patient is a 74-year-old female that presents to the office today for her yearly
Medicare wellness exam. The patient has multiple chronic conditions according to the patient’s
report.
Social History:
The patient lives in a single-story home with handrails at the steps. She is married and has 2
adult children. The patient’s daughter and son will come by and visit at least 3 times per week
and help with taking the trash out, laundry, and assisting her with picking up groceries. The
patient is retired from being a bank teller for more than 40 years. The patient reports she has
never smoked and denies any other forms of nicotine. The patient denies any alcohol usage or
illicit drugs. However, she does drink a moderate amount of caffeine daily. The patient reports
being able to perform all ADL’s independently, she reports her children come to help her without
being asked for help. Patient denies having difficulty seeing, hearing, concentrating,
remembering or making decisions. She can climb stairs, run errands and dress herself without
difficulty or assistance. Patient reports her right hand is her dominant hand. Patient denies having
smoke detectors or carbon monoxide detectors in her home- I gave her information on the local
fire department will install those for free. Patient reports feeling restless and anxious to some
extent, it is affecting her sleep. The patient reports she is sexually active and monogamous. She
does have an advance directive, power of attorney, will accept blood in case of an emergency
and is a full code. Patient admit to regular exercise with no dietary restrictions.
Family History: Father- essential hypertension died at 67, Mother- essential hypertension,
hyperlipidemia, malignant tumor of breast, disorder of thyroid gland, died at 92, paternal
grandmother- essential hypertension, and arthritis, died at 72, maternal grandfather-
hyperlipidemia, coronary arteriosclerosis, died at 62, maternal grandmother- malignant neoplasm
of uterus, died at 58.
Surgical History: Cholecystectomy on 07/16/2018.
Hospitalizations: Denies any hospitalizations other than when she gave vaginal birth to her
children.
PMH: Hypothyroidism, perennial allergic rhinitis, heterozygous methylenetetrahydrofolate
reductase mutation, generalized anxiety disorder, gastroesophageal reflux disease, erosive
osteoarthritis, osteopenia, and mixed hyperlipidemia.
Allergies: Amoxicillin (itching, mild reaction) (rash, mild), Bactrim (itching, mild), Cefdinir
(itching, mild), Keflex (itching, mild) (rash, mild), Levaquin (unknown reaction)
, 3
Medications:
- Cetirizine 10mg tablet PO BID for allergic rhinitis
- Atorvastatin 20mg tablet PO daily for hyperlipidemia
- Azelastine 137mcg nasal spray aerosol, instill 2 sprays per nostril for allergic rhinitis.
- Biotin 1mg tablet PO daily for B vitamin supplement
- Cholecalciferol 50mcg tablet PO daily for vitamin D3 supplement for Osteopenia.
- Fish Oil 1000mg capsule PO daily to help reduce pain and swelling in joints.
- Fluticasone Propionate 50mcg/nasal spray for allergic rhinitis.
- L- Methylfolate 15mg tablet PO daily to help reduce anxiety.
- Synthroid 25mcg tablet PO daily for hypothyroidism
- Vitamin C 1000mg tablet PO daily for Osteopenia.
- Voltaren 1% topical gel apply 2 grams to the affected area by topical route every 6 hours
as needed per day for joint pain- Erosive Osteoarthritis.
Environmental Factors/Immunizations/Health Prevention: Last pap smear was 08/15/2021
with normal results. Patient has never had an abnormal pap smear. Denies ever having the HPV
vaccine. Age of menopause was 55. Age of first child was 24. Had Moderna Covid-19
vaccination x2 on 2/23/21 and 3/23/21 with a booster on 1/14/22. Most recent Tdap vaccine was
05/24/23. Influenza vaccine was on 10/23/23. Last Pneumococcal vaccine was 11/14/17 and
patient agrees to received one today. Zoster two shot series is up to date (07/29/22 and 11/17/22).
The patient’s last mammogram was 1/10/23 and has one scheduled for after the first of the year.
Patients last colonoscopy was 07/16/18 with normal results. Patient has denied scheduling a
colonoscopy at this time. Dental exam every 6 months. Last eye exam was 09/12/23. Hearing
screen 11/2022, normal results. DEXA scan 1/10/23 which showed Osteopenia of the lumbar
spine and left femoral neck.
ROS
Constitutional: The patient reports occasional fatigue but denies fever, chills, or unintentional
weight loss.
Skin: Reports changes in skin texture, occasional dryness, and a few age spots. No history of
skin cancers or significant rashes.
HEENT: Reports occasional dry eyes and mild vision changes. No history of eye infections or
significant hearing loss. Occasional seasonal allergies, managed with OTC medications.
No history of frequent headaches or head injuries. Denies dizziness or vertigo. No issues with
taste or smell.
Cardiovascular: Denies chest pain, palpitations, or shortness of breath. Reports occasional mild
swelling in ankles after prolonged standing.
Respiratory: Denies chronic cough, wheezing, or shortness of breath. No history of chronic
respiratory conditions.
Abdominal/GI: Reports occasional indigestion and constipation. No significant abdominal pain,
nausea, or vomiting. No history of GI bleeding.
