iHuman Week 9 NURS 2026 Case Study: 49Year-
Old Shane Peterson Annual Physical Exam
| Comprehensive SOAP Note, Preventive
Screening & Evidence-Based Health Assessment
Patient Information
Name: Shane Peterson
Age: 49 years
Gender: Male
Race: Caucasian
Visit Type: Annual Physical Examination
Setting: Outpatient Primary Care Clinic
,Source of History: Patient (reliable)
S – Subjective Data
Chief Complaint
“I’m here for my yearly physical. I feel generally healthy but want to make sure everything is
okay.”
History of Present Illness
Shane Peterson is a 49-year-old male presenting to the primary care clinic for a routine
annual physical examination and preventive health evaluation. The patient reports no acute
complaints today. He states that he feels generally healthy and denies recent illness, weight
changes, or significant fatigue.
He notes occasional mild work-related stress but reports adequate sleep averaging 6–7 hours
per night. He denies chest pain, shortness of breath, dizziness, palpitations, or syncope. He also
denies gastrointestinal complaints, urinary symptoms, or neurological concerns.
The patient reports he has not had a colon cancer screening yet and is interested in learning
about recommended screenings as he approaches age 50. He reports moderate physical activity
but acknowledges his diet could be improved due to frequent consumption of fast food during
busy workdays.
He denies recent hospitalizations or emergency visits.
Past Medical History
• Mild hyperlipidemia diagnosed 3 years ago
• Seasonal allergic rhinitis
• No history of diabetes or hypertension
, Past Surgical History
• Appendectomy at age 20
• No complications
O – Objective Data
Vital Signs
• Blood Pressure: 128/82 mmHg
• Heart Rate: 74 bpm
• Respiratory Rate: 16/min
• Temperature: 98.4°F (36.9°C)
• BMI: 27.6 kg/m² (Overweight)
Physical Examination
General
Alert, oriented, well-appearing male in no acute distress.
HEENT
Head atraumatic and normocephalic. Pupils equal, round, reactive to light. Extraocular
movements intact. Tympanic membranes normal. Oral mucosa moist without lesions. Neck
Supple, no lymphadenopathy or thyroid enlargement.
Cardiovascular
Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses intact.
Respiratory
Clear to auscultation bilaterally. No wheezes or crackles.
Abdomen
Old Shane Peterson Annual Physical Exam
| Comprehensive SOAP Note, Preventive
Screening & Evidence-Based Health Assessment
Patient Information
Name: Shane Peterson
Age: 49 years
Gender: Male
Race: Caucasian
Visit Type: Annual Physical Examination
Setting: Outpatient Primary Care Clinic
,Source of History: Patient (reliable)
S – Subjective Data
Chief Complaint
“I’m here for my yearly physical. I feel generally healthy but want to make sure everything is
okay.”
History of Present Illness
Shane Peterson is a 49-year-old male presenting to the primary care clinic for a routine
annual physical examination and preventive health evaluation. The patient reports no acute
complaints today. He states that he feels generally healthy and denies recent illness, weight
changes, or significant fatigue.
He notes occasional mild work-related stress but reports adequate sleep averaging 6–7 hours
per night. He denies chest pain, shortness of breath, dizziness, palpitations, or syncope. He also
denies gastrointestinal complaints, urinary symptoms, or neurological concerns.
The patient reports he has not had a colon cancer screening yet and is interested in learning
about recommended screenings as he approaches age 50. He reports moderate physical activity
but acknowledges his diet could be improved due to frequent consumption of fast food during
busy workdays.
He denies recent hospitalizations or emergency visits.
Past Medical History
• Mild hyperlipidemia diagnosed 3 years ago
• Seasonal allergic rhinitis
• No history of diabetes or hypertension
, Past Surgical History
• Appendectomy at age 20
• No complications
O – Objective Data
Vital Signs
• Blood Pressure: 128/82 mmHg
• Heart Rate: 74 bpm
• Respiratory Rate: 16/min
• Temperature: 98.4°F (36.9°C)
• BMI: 27.6 kg/m² (Overweight)
Physical Examination
General
Alert, oriented, well-appearing male in no acute distress.
HEENT
Head atraumatic and normocephalic. Pupils equal, round, reactive to light. Extraocular
movements intact. Tympanic membranes normal. Oral mucosa moist without lesions. Neck
Supple, no lymphadenopathy or thyroid enlargement.
Cardiovascular
Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses intact.
Respiratory
Clear to auscultation bilaterally. No wheezes or crackles.
Abdomen
