Tina Jones- Week 9 SH Comprehensive SOAP
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Note Advanced Health Assessment (Walden
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Univers, Exams of Nursing
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, Week 9 b3
Shadow Health Comprehensive SOAP Note Template b3 b3 b3 b3 b3
Patient Initials: TJ b3 b3 Age: 28 b3 Gender: Female b3
SUBJECTIVE DATA: b3
Chief Complaint (CC): b3 b3
"I came in because I'm required to have a recent physical exam for the health insurance at my
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new job."
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History of Present Illness (HPI): b3 b3 b3 b3
Presents for a general physical examination in preparation for her new position as
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an accounting clerk at Smith, Stevens, Silver & Company. She denies having any
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serious issues. She visited a gynecologist for a checkup four months prior, during
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which a PCOS diagnosis was made, and a daily birth control regimen was prescribed.
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She states that (Drospirenone/ethinyl estradiol) is taken consistently every day with
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satisfactory symptom management. She had a physical examination five months
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prior, during which she was prescribed Metformin for her diabetes and a daily inhaler
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every day for her asthma. Her vision is now clearer, and she no longer experiences
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migraines after seeing an eye doctor three months ago. She claims that metformin,
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a healthy diet, and exercise are helping her manage her diabetes. She routinely
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monitors her blood sugar levels each day. The last time a rescue inhaler was used
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was three months ago with usage reducing to twice yearly. The patient keeps a journal
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and measures her peak flow at home.
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Medications:
• Metformin 850mg PO BID (last taken today) b3 b3 b3 b3 b3 b3
• Flovent 110mcg/spray 2 puffs BID (last taken today) b3 b3 b3 b3 b3 b3 b3
• Proventil 90mcg/spray 2 puffs PRN for wheezing and shortness of breath (last
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used 3months ago)
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• Drospirenone/Ethinyl Estradiol Birth Control 1 tablet PO daily (last taken today) b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
Allergies:
• Penicillin: causes a rash. b3 b3 b3
• Denies food allergies. b3 b3
• Denies latex allergy. b3 b3
© 2021 Walden University, LLC
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Note Advanced Health Assessment (Walden
b3 b3 b3 b3 b3
Univers, Exams of Nursing
b3 b3 b3 b3
, Week 9 b3
Shadow Health Comprehensive SOAP Note Template b3 b3 b3 b3 b3
Patient Initials: TJ b3 b3 Age: 28 b3 Gender: Female b3
SUBJECTIVE DATA: b3
Chief Complaint (CC): b3 b3
"I came in because I'm required to have a recent physical exam for the health insurance at my
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
new job."
b3 b3
History of Present Illness (HPI): b3 b3 b3 b3
Presents for a general physical examination in preparation for her new position as
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b 3
an accounting clerk at Smith, Stevens, Silver & Company. She denies having any
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
serious issues. She visited a gynecologist for a checkup four months prior, during
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
which a PCOS diagnosis was made, and a daily birth control regimen was prescribed.
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
She states that (Drospirenone/ethinyl estradiol) is taken consistently every day with
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
satisfactory symptom management. She had a physical examination five months
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
prior, during which she was prescribed Metformin for her diabetes and a daily inhaler
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
every day for her asthma. Her vision is now clearer, and she no longer experiences
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
migraines after seeing an eye doctor three months ago. She claims that metformin,
b3 b3 b3 b3 b3 b3 b3 b 3 b3 b3 b3 b3 b3
a healthy diet, and exercise are helping her manage her diabetes. She routinely
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
monitors her blood sugar levels each day. The last time a rescue inhaler was used
b3 b3 b3 b3 b3 b3 b 3 b3 b3 b3 b3 b3 b3 b3 b3
was three months ago with usage reducing to twice yearly. The patient keeps a journal
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
and measures her peak flow at home.
b3 b3 b3 b3 b3 b3 b3
Medications:
• Metformin 850mg PO BID (last taken today) b3 b3 b3 b3 b3 b3
• Flovent 110mcg/spray 2 puffs BID (last taken today) b3 b3 b3 b3 b3 b3 b3
• Proventil 90mcg/spray 2 puffs PRN for wheezing and shortness of breath (last
b3 b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
used 3months ago)
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• Drospirenone/Ethinyl Estradiol Birth Control 1 tablet PO daily (last taken today) b3 b3 b3 b3 b3 b3 b3 b3 b3 b3
Allergies:
• Penicillin: causes a rash. b3 b3 b3
• Denies food allergies. b3 b3
• Denies latex allergy. b3 b3
© 2021 Walden University, LLC
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