1Week 9 Patient Comprehensive ExamWalden Universit

1
Week 9 Patient Comprehensive Exam
Walden University
NURS 6512 Advanced Health Assessment
Dr. Vijayarani Suresh
August 2, 2021
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Week 9 Patient Comprehensive Exam
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: T.J. Age:28 Gender: female

SUBJECTIVE DATA:
Chief Complaint (CC): “I’m here because I need a physical for
my new job.”
History of Present Illness (HPI): T.J. is a 28-year-old African
American female who is
here today for a general physical for a new job as an accounting
clerk soon. She is
oriented to person, place, and time. She is calm, pleasant, and
attentive. T.J. has dressed
appropriately for the season and is a good historian.
Medications: Metformin 850mg BID, last dose this morning
Flovent Inhaler two puffs twice daily, last used this morning
Albuterol Inhaler for rescue hasn’t been used recently. She
states approximately three
months ago and has only used it twice last year.
Drospirenone/Ethinyl estradiol birth control, one pill daily. She
started taking these four
months ago and was prescribed by her GYN MD. Last dose this
morning.
Ibuprofen and Tylenol as needed
Allergies: Cats: makes asthma worse. PCN: “Not sure; I have
been told this since I was a
child.” Denies any food allergies. She denies latex allergy. She
states she does have some
environmental allergies.
Past Medical History (PMH): The patient has asthma, PCOS,
and Type II Diabetes. She
states she checks her glucose every morning, and they have
been stable. She has had
GERD in the past; however, she isn’t currently taking

medication. She has only been
hospitalized for asthma as a child that she remembers and never
for surgery. The patient
denies any severe injuries that would impair her. T.J. was seen
for heart palpitations that
since then have subsided. She has been monitoring her blood
pressure as it has fluctuated
at times but has now been normal. Last menstrual cycle was
approximately two weeks
ago. The patient has never been pregnant and is up to date on
her immunizations except
for the influenza vaccine. She recently had a routine pap smear;
however, she needs to be
educated on how to do self-breast exams, as she states she has
only had a doctor perform
this and doesn’t know what to look for. She denies any
depressive or anxiety symptoms.
She has never had thoughts of harming herself or others, and
She denies having a
transfusion. The patient states she was seen here a few months
ago for a foot injury that
since then has subsided. She has back issues at times but is
currently feeling well. The
3

patient had a recent dental visit and was prescribed new glasses
at her recent eye
appointment.
Past Surgical History (PSH): none
Sexual/Reproductive History: The patient states she has never
been pregnant and is not
currently sexually active. She has a new boyfriend and says that
she will be having sex
with him soon. The patient denies any STDs and thought she
had been tested when she
was at the GYN a few months back. The patient is currently on
birth control and is aware
of safe sex precautions. The patient states her menstrual cycle is
much improved after
being put on birth control. It is once a month and lasts
approximately five days each
month.
Personal/Social History: T.J. has recently taken a new position
as an accounting clerk
for Smith, Stevens, Stewart, Silver, and Company. The patient
is a college graduate,
received her B.A. a few years ago. She will be helping an
experienced accountant until
she can build her client list. The patient has recently lost ten
pounds per self-report and is
exercising 4-5 times a week. She has also been swimming with
her best friend, Selena.
The patient is taking better care of her blood sugars by
regulating her diet. She states she
is eating fewer carbohydrates and “only a candy bar once in a
while.” The patient has
been introducing more vegetables and fruit into her diet. The
patient limits her caffeine to

two diet cokes per day. She denies substance abuse and only has
alcohol “when she is out
with her friends.” The patient hasn’t used tobacco. She
currently still lives with her
mother and younger sister but states she will be moving out in
the next few months. She
controls her stress by exercising and see a therapist when she
needs to. She says talking
helps a lot with anxiety. She enjoys going to church, bible
study, and watching science
documentaries.
Health Maintenance: The patient has had all yearly health needs
met, except for doing
self-breast-exams to provide education for her. Will need
Immunization History: All immunizations are up to date. The
patient didn’t receive the
influenza vaccine this year.
Significant Family History: Mother is alive and well, has a
history of hypertension and
high cholesterol, father died approximately two years ago in a
car accident. He had
hypertension, high cholesterol, and diabetes. Maternal
grandmother died at age 73 from a
stroke, and maternal grandfather passed away at age 80 from a
heart attack. Paternal
grandmother is alive, age 82, and has hypertension and high
cholesterol. Her paternal
grandfather died of colon cancer in his mid-sixties. He also had
hypertension and
diabetes. Sister, age 14, alive and well, does have asthma that is
well controlled. Her
brother is 25 and is overweight. Her paternal uncle has
alcoholism.

Review of Systems:
4
General: The patient denies any fever, chills, or night sweats.
She denies any
nausea or vomiting. The patient is slightly overweight but
overall in good health.
HEENT: The patient wears glasses and had a vision exam. She
denies getting any
headaches since she was prescribed her new glasses. No double
vision, and she hasn’t
ever had a head injury. The patient denies eye injuries or
surgeries—no changes in smell,
no epistaxis, or sinus problems. No ear problems state she
“hears just fine.” She has had a
recent dental exam, no mouth sores, no gingivitis, no bleeding
gums.
Breasts: The patient denies noticing any lumps; however, she
states she doesn’t know
what the patient is looking for, so she doesn’t regularly check.
Educated on self-breast
exams. No nipple discharge or drainage.

Respiratory: The patient has asthma, has two inhalers for this,
only uses her
rescue inhaler “couple times per year.” No recent
hospitalizations for asthma. No history
of pneumonia, hemoptysis, last tuberculosis testing “couple
years ago.”
Cardiovascular/Peripheral Vascular: The patient has a history of
palpitations;
however, it has been resolved. The last EKG was normal sinus
rhythm approximately
four months ago. She denies shortness of breath unless “running
upstairs” or being
“around cats.” No chest pain and no edema were noted. She can
breathe out of her nose
with no issues.
Gastrointestinal: She denies a history of abdomen pain, no
constipation, or
diarrhea. No changes in bowel habits. The patient does not use
any laxatives and states
she “drinks plenty of water.” Denies any hematochezia,
hematemesis, or hemorrhoids.
She had been seen in the clinic for GERD a while back but is
currently not having
symptoms.
Genitourinary: The patient denies any urgency, frequency,
dysuria, polyuria, or
incontinence. No history of STDs. She denies a history of UTIs.
The patient has never
been pregnant, is currently on birth control States The periods
are regular and only lasting
approximately five days. Last pelvic exam about four months
ago with a pap smear.

Musculoskeletal: Denies muscle or joint pain. She states she
hurt her back a
while back helping her friend move but saw a physical therapist,
and it is much better.
The patient has had no fractures.
Neurological: Reports no vertigo, no vision disturbances, no
numbness or
tingling, no loss of coordination, no seizure activity. She denies
any balance issues.
Endocrine: states diabetes has improved, and her blood sugars
daily have been running
around 90. She has been watching her diet more and states she
has lost 10 pounds. She
takes metformin as prescribed.
Psychiatric: Feels less stressed after graduating and getting a
new job. She states
she is pretty excited about her new employment. She sees a
therapist when needed and
says that this helps. She has no psychiatric medications
prescribed. The patient sleeps
eight to nine hours per night.
Skin/hair/nails:
The patient denies any rashes or sores that won’t heal. She does
use sunscreen daily,
especially when exercising. She states her acne is improving
after being placed on birth
control; however, she sees some male pattern hair growth. No
changes in moles and
doesn’t have dandruff. She reports no nail fungus or dry skin.

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OBJECTIVE DATA:
Physical Exam:
Vital signs: Blood pressure 128/82 pulse 78, respirations 15
pulse ox 99% temp 37.2C
General: The patient is a 28-year-old African American female
starting a new job as an
accounting clerk in approximately two weeks. The patient is
alert and oriented x 3,
appears well-nourished, and in good spirits.
HEENT: Head normocephalic, atraumatic. No tenderness or
bruit was noted in the
temporal area. Pupils are reactive to light and accommodation.
No orbital edema, no palpated
nodules on eyes, the patient wears glasses. The patient denies
any vision issues. The vision was
20/20 with screening. Ears are pink and dry, with no pain or
drainage from canals. The tympanic
membrane is intact and pearly gray. Whisper voice test positive
for hearing. No dandruff is
noted, and hair is distributed evenly. Did note increased facial
area noted above lip and sides of
the hairline. Acne and acne scarring were noted. Some papules
are scattered on the right side of
the face, more prominent than typical acne lesions. The nose is

patent, with no drainage noted.
The septum is midline. The throat is moist and pink, tonsils
present with no edema. No exudate
was noted. No lesions were noted, teeth intact. Lips are wet and
smooth in texture—gag reflex
present. The jaw has good ROM with no clicks.
Neck: Good ROM, no lymph nodes palpated, axillary or
supraclavicular. Thyroid
smooth without nodules and no goiter present. The neck is
supple with no adenopathy, No JDV.
Did note skin thickening with verrucous texture around the
entire neck.
Chest/Lungs: Appears symmetric, without any rashes or
deformity. The chest wall is
non-tender to palpitation. Lungs are clear throughout all fields.
On percussion, resonance is
noted throughout. The spirometer test patient performed had an
FVC of 1.78 and FEV1 1.549.
Voice muffled throughout when patient stated “99” when
prompted. No cough. Fremitus is equal
bilaterally in both upper and lower anterior chest walls.
Heart/Peripheral Vascular: No edema noted in extremities. The
chest is symmetrical,
with no apparent abnormalities noted. PMI is non-displaced,
with no heaves or lifts. S1 and S2
audible with no adventitious sounds noted. Heart rate and
rhythm are regular. Capillary refill in
both fingers and toes is less than 3 seconds. Radial, brachial,
femoral-popliteal pulse are +2
bilaterally, Posterior tibial and dorsalis pedis are also +2
bilaterally.
The carotid artery was 2+, and no thrill was noted bilaterally;

right and left renal arteries
had no bruit, and no bruit was noted at the aorta. Right and left
iliac had no bruit, and right and
left femoral had no bruit noted.
Abdomen: The abdomen is soft, round, symmetric, and non-
tender. No distention was
noted. There are visible striae on the belly and hair from the
pubis to the umbilicus. The
umbilicus is midline with no herniation visualized. Bowel
sounds active x 4 quadrants—no aortic
bruit or CVA tenderness. Spleen percussion was dull, and liver
span measured 7 cm MCL per
percussion. No tenderness or masses with light palpation of the
abdomen, no masses, guarding,
or rebound noted with deep palpation. Able to palpate liver 1cm
below the right costal margin.
Spleen and kidneys are not palpable and without masses.
Genital/Rectal: Deferred as a patient recently had a pap smear
and pelvic exam. No
hemorrhoids or bleeding from the rectum was noted.
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Musculoskeletal: Arms and legs are symmetrical, and no edema

was noted. No joint
swelling, redness, or tenderness was noted. Strength tests on
extremities, both proximal and
distal, were 5/5.
Neurological: The patient can state her name, date of birth, and
the building. She is also
able to states the correct date and year. Heel to shin test
performed: patient able to make a
straight path down the shin without any difficulty. She can close
her eyes and touch her nose
with both index fingers. The patient can move her hands and
arms with regular and rapid
smoothness. When testing the patient’s feet, it was noted that
she had lost some sensation in her
left and right great toes, left forefoot under the great toe, and
left small toe. Deep tendon reflexes
are 2+ on bilateral triceps, biceps, and bilaterally
brachioradialis. Left and right deep tendon
reflexes of the knee are 2+ and the right and left Achilles’
reflex is 2+. Graphesthesia is intact in
both hands as well as stereognosis is intact. Position sense is
entire in toes and fingers.
Skin: Acne/folliculitis noted on the right side of the face, few
papules on the left side of
the face. There is excessive hair growth above the upper lip and
on both sideburn, areas, and in-
between pubis and umbilicus—noted skin thickening around the
neck with slight verrucous
texture (Acanthosis nigricans). Also noted upper back area,
small discolored patches. They are
primarily hypopigmented areas covering the majority of the
upper back.
Diagnostic results:

1) Type II Diabetes: The patient has a diagnosis and is currently
on metformin 850mg BID.
Would need HgA1c, fasting glucose, lipid panel, cholesterol.
Type II diabetes is most
likely to develop if the patient is overweight, has a family
history of diabetes, is black,
has high blood pressure, and is heavy (Type 2 Diabetes, 2021).
The patient, in this case,
meets all of these criteria.
2) Asthma: The patient used a Flovent inhaler and has a rescue
inhaler as need. Adult-onset
asthma is asthma that develops as an adult, usually over the age
of 20. If the patient had
childhood asthma, is female after the age of 20, is overweight,
has relative asthma,
around people who smoke or have allergies, they are more
susceptible (Adult-onset
Asthma: Causes, Symptoms, Treatment and Management, 2021).
This patient fits the
criteria for this diagnosis as well. Labs to consider for this
diagnosis would be CBC,
routine FEV1/FVC ratio, peak expiratory flow rate, and chest x-
ray.
3) PCOS: The patient has this diagnosis and is currently being
treated with birth control
medication. Patients with this diagnosis may see the irregular
menstrual cycle, too much
hair on the face, chin, and parts of the body that men usually
have hair, weight gain,
darkening of the skin, especially around the neck, and skin tags
(Polycystic Ovary
Syndrome, 2021). This patient meets all these criteria for this
diagnosis. Labs considered

for this diagnosis would be serum 17-hydroxyprogesterone,
prolactin, androgen hormone,
TSH, oral glucose test, fasting lipid panel, and pelvic
ultrasound.
ASSESSMENT:
PLAN: This section is not required for the assignments in this
course (NURS 6512) but will be
required for future courses.
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References
Adult-onset Asthma: Causes, Symptoms, Treatment, and
Management. (2021). Global Allergy
and Airway Patient Platform. http://gaapp.org
Polycystic Ovary Syndrome. (2021). U.S. Department of Health
and Human Services.
http://womenshealth.gov
Type 2 Diabetes. (2021). American Association of Clinical

Endocrinology. http://aace.com
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Nursing 6512
Advanced Health Assessment & Diagnostic Reasoning
Episodic/Focused SOAP Note
Review of Case #3
Week 9 Initial Post
Patient Initials: K. T. Age: 33 Gender: F Ethnicity:
African American
SUBJECTIVE DATA:
Chief Complaint (CC): “Drooping on the right side of face”
History of Present Illness (HPI): MH is a 33-year-old Caucasian
female
presents to the office today with right side facial drooping that
she

observed when she woke up this morning. She says that her
right eye has
been watering constantly, and that she can’t stop drooling out of
the right
side of her mouth. She denies any pain.
Medications:
Ibuprofen 200mg-2 PO as needed
Tylenol 325mg-2 PO every 4 hours as needed
Woman’s Multivitamin daily
Allergies: No Known Allergies
Past Medical History (PMH): Diagnosed with asthma when she
was a
child. All immunizations are up to date. Denies ever having any
surgeries
or hospitalizations.
https://www.coursehero.com/file/34880905/Nursing-6512-
Week-9-Discussion-docx/

Social History: K. T. is a heterosexual, sexually active
individual who
lives with her husband and children. She denies any tobacco,
alcohol or
illicit drug use & wears her seatbelt whenever operating a motor
vehicle.
She enjoys time with her family, evening walks with her
children when
weather permits and front porch sitting with a good book in
hand. She
denies any issues with sleep and reports getting approximately
8-10 hours
of sleep a night.
Family History: Both of her parents are still living. Her father is
55 with a
history of arthritis and hypertension. Her mother is 54
without any
significant health history. Her younger sister, age 30, does not
have any
significant health history. She has two children, ages 7 &
5 who are
healthy.
Review of Systems (ROS):

General: No unexplained weight loss or weight gain, no
decreased
appetite, no fever, chills or fatigue
HEENT: No blurred or loss of vision, no loss of hearing,
hearing difficulty
or ringing in ears, no congestion, runny nose, sore throat or
hoarseness,
no swelling/tenderness in lymph nodes.
Skin: No changes in skin such as rashes, lesions dryness or
persistent
itching
Respiratory: No SOB, cough or sputum production.
Cardiovascular: No chest pain, pressure or palpitations, no
edema or
pain with walking
Gastrointestinal: No change in bowel habits, indigestion,

nausea/vomiting or diarrhea. No abdominal pain or tenderness
Genitourinary: No burning with urination, itching, difficulty
starting
stream or increased frequency
Musculoskeletal: No muscular or joint pain
Hematologic: No anemia or bleeding, not easily bruised
Endocrinological: No heat or cold intolerances, no sweating, no
polyuria
or polydipsia.
Neurological: No dizziness, LOC, or headaches. Moves all
extremities
without tremors
Psychiatric: No mental illness, depression or anxiety
OBJECTIVE DATA:
Physical Exam:
Vital Signs: Temp: 98.2. Pulse: 82, Respirations: 20 and
non-labored.
SpO2: 100% on RA, BP: 116/72 mmHg. Weight 140lbs. H: 5’8’
BMI: 21.3
General: Well-groomed and well-nourished, answering
questions

appropriately
HEENT: Normocephalic, atraumatic, wears glasses, no hearing
difficulties,
good oral hygiene, no swelling/tenderness in lymph nodes.
Skin: Intact, appropriate for ethnicity, no rashes, lesions
dryness
Cardiovascular: No chest pain or palpitations. RRR without
murmur, no
edema, pulses palpable bilaterally to lower extremities, cap
refill greater
than 3 seconds
Respiratory: No SOB, chest expansion equal and symmetric
with clear
lung sounds, no cough or sputum production.
Gastrointestinal: No nausea, vomiting, diarrhea, or
discomfort,

nondistended, nontender, BS present, and normoactive x4,
no
organomegaly.
Genitourinary: Genitalia not examined. No dysuria or
incontinence.
Neurological: AOx4, + for paresis on right side of face, + for
difficulty
making facial expressions, moves all extremities without
tremors or
weakness
Psychiatric: Calm, cooperative, concerned about symptoms
Allergic/Immunologic: No known allergies, no immune
deficiencies.
ASSESSMENT:
Lab Tests:
Complete blood count to assess for possible infectious causes
Enzyme-linked immunosorbent assay [ELISA] or Enzyme
immunoassay
[EIA] to assess for Lyme’s
Diagnostics:

Computed Tomography (CT) or magnetic resonance imaging
(MRI) to
identify infection, inflammation, tumor, fractures, or other
potential
causes for facial nerve involvement.
Electromyography (EMG) testing - A test in which a needle
electrode is
inserted into affected muscles to record both spontaneous
depolarizations and the responses to voluntary muscle
contraction.
Electroneuronography (ENoG) testing (neurophysiologic
studies) - A
test used to examine the integrity of the facial nerve, in which
surface
electrodes record the electrical depolarization of facial
muscles
following electrical stimulation of the facial nerve.

Glasgow Coma Scale & NIH Stroke Scale – to rule out stroke
Cerebrospinal fluid (CSF) analysis - to identify the
presence of
increased protein and white blood cells; for this test, a
needle is
inserted into the spine between vertebrae and a small amount of
fluid
is withdrawn. While some protein is normally present, an
increased
amount without an increase in the white blood cells in the CSF
may be
indicative of Guillain-Barré syndrome.
Diagnosis:
Bell’s Palsy – According to Baugh, et al (2013). Bell's Palsy,
named
after the Scottish anatomist, Sir Charles Bell, is the most
widely
recognized acute mono-neuropathy, or on the other hand
issue
influencing a solitary nerve, and is the most normal
determination
related with facial nerve weakness/loss of motion. Bell's
Palsy is a

sudden one-sided facial nerve paresis (weakness) or loss
of motion
(complete loss of development) of obscure reason. The
condition
prompts the fractional or complete failure to deliberately move
facial
muscles on the influenced side of the face. Albeit
commonly self-
constrained, the facial paresis/loss of motion that happens
in Bell's
palsy may cause noteworthy brief oral ineptitude and a
powerlessness
to close the eyelid, prompting potential eye damage.
Differential Diagnoses:
Facial Nerve Schwannomas - Facial nerve schwannomas (FNSs)
are
slow-growing developing favorable tumors that can occur

along any
section of the facial nerve. Indications can be variable relying
upon the
size and area of the tumor, yet usually incorporate facial
paresis,
hearing loss, and vestibular side effects (Jacob, Driscoll, &
Link, 2012).
Guillain-Barre Syndrome: Typically starts as paresthesia and
weakness and continuously rising, manifestations
incorporate facial
droop, diplopia, dysphagia, dysarthria, and pupillary
aggravations
(Andary, 2017).
Mastoiditis - a bacterial contamination of the temporal
bone and
gives the accompanying side effects; otalgia, otorrhea,
swelling,
delicacy, and facial paralysis is an intra-transient complication
(Devan,
2016).

Stroke – Strokes often present with facial drooping, but it
usually
affects one side of the body. If a patient can raise their
eyebrows
normally and symmetrically but the lower part of their
face is
paralyzed the health care provider will need to rule out a stroke
(EBM
Consult, 2015).
Lyme disease – Lyme Disease is a disease caused by bacteria
that
ticks can carry. It can cause bell’s palsy because advanced
symptoms
of Lyme disease can affect the nervous system (Roth & Cirino,
2016).
References
Andary, M. (2017). Guillain-Barre Syndrome. Retrieved
fromhttp://emedicine.medscape.com
/article/315632-overview

Baugh, R. F., Basura, G. J., Ishii, L. E., Schwartz, S. R.,
Drumheller, C. M.,
Burkholder R., Deckard, N. A.,
Dawson, C., Driscoll, C. M., Gillespie, B., Gurgel, R. K.,
Halperin, J.,
Khalid, A. N., Kumar, K. A., Micco, A., Munsell D.,
Rosenbaum, S., and
Vaughan, W. (2013). Clinical Practice Guideline: Bell’s Palsy.
Otolaryngology–Head and Neck Surgery. 149(3), pp. S1 - S27.
https://doi.org/10.1177
/0194599813505967
Devan, P. P. (2016). Mastoiditis clinical presentation. Retrieved
from
http://emedicine.medscape.com/
article/2056657-clinical#b3

EBM Consult. (2015). Stroke vs. bell’s palsy. Retrieved from
http://www.ebmconsult.com/articles/anatomy
stroke-vs-bells-palsy
Hinckley, A. F., Connally, N. P., Meek, J. I., Johnson, B. J.,
Kemperman, M. M.,
Feldman, K. A.,
White, J. L., & Mead, P. S. (2014). Lyme Disease Testing by
Large
Commercial Laboratories in the United States. Clinical
Infectious
Diseases, (59)5, pgs. 676–681,
https://doi.org/10.1093/cid/ciu397
Jacob, J. T., Driscoll, C. L. W., & Link, M. J. (2012). Facial
Nerve Schwannomas
of the Cerebellopontine
Angle: The Mayo Clinic Experience. Journal of Neurological
Surgery. Part
B, Skull Base, 73(4), 230–235. http://doi.org/10.1055/s-0032-
1312718
National Institute of Neurological Disorders and Stroke. (2018).
Bell’s Palsy.
Retrieved from

https://www.ninds.nih.gov/Disor ders/All-Disorders/Bells-Palsy-
Information-Page
Roth, E. & Cirino, E. (2016). Is it Lyme disease? Check
your symptoms.
Retrieved from
http://www.healthline.com/health/lyme-disease-
symptoms#Overview1
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Vitals
Student Documentation

Model Documentation
Vitals
BP 120/82 SPO2 - 99 RR - 15 T - 37.2
N/A
Health History
Model Documentation
Identifying Data & Reliability
Ms. Tina Jones is a 28 years old African American female. Not
married and does not have children, currently in relationship
with a boyfriend. Presently living with her mother and young
sister. Ms. Jones presents to our consult for physical assessment
as she newly got hired by a new employer. She is alert, allowing
the pertinent data and well articulate. She is able to maintain
eye contact, appropriately communicate and engage in the
assessment.
N/A
General Survey
Ms. Jones is alert, engaged in her health matters and compliant
with the follow ups. Seating in upright posture, articulate, with
not stressed appearance , groomed well nourished ,
appropriately dressed and maintains good hygiene.
N/A
Reason for Visit
" I came because I 'am required to have a recent physical exam
for the health insurance at my new job"
N/A
History of Present Illness
Ms. Jones 28 years old African American female that presented
for physical examination for the insurance of new job. She
states that she does not have any present medical concern. The
patient does have history of Diabetes, asthma and High blood
pressure. The patient was prescribed with metformin around 5
months ago during her last physical exam, and also was
diagnosed with PCOS by ger gynecologist at this time birth
control medication was prescribed. Ms Jones reports some side

effects associated with metformin , but also stated that those
side effects were managed using yogurt. She stated stopping the
use of Advil for cramps. MS Jones claims to be feeling
currently healthy and looking forward the new employment.
N/A
Medications
Advil for cramps occasionally Metformin 850 mg twice a day
Flovent daily inhaler and Proventil as a recue inhaler , she is
presently using estradiol as birth control medication.
N/A
Allergies
Not food allergies identified. Allergic to cats and dust , she is
also allergic to penicillin that given her rushes.
N/A
Medical History
Ms, Jones was diagnosed with asthma when she was 2 years old,
for which presently she use Flovent and Proventil in the
morning and evening. She is allergic to cats and dust. She was
also diagnosed with diabetes 4 years ago and now treated with
metformin she started treatment 5 months ago. She has been
regularly checking her blood sugar since and stated currently
being in the 90's. She reported that initially she had some side
effects from metformin , but she had since manage it . She also
has High Blood pressure, which she has been able to manage
with exercises and diet. She stated being heterosexual , does not
have STDs and has been sexually inactive for while but
presently she does have a boyfriend, About 5 months ago Ms.
Jones was diagnosed with POCS and estradiol was prescribed.
She reported using Advil occasionally for cramps.
N/A
Health Maintenance
Ms. Jones is aware of the importance of dieting and exercise
and expressed being engaged in both. She stated being active
physically. She stated she does not strain herself and does not
have any breathing problems. As per patient she occasionally
goes swimming with friend and plays active roles in the church.

Ms Jones last physical examination was 5 months ago , her
immunization are up to date , she had a tetanus booster about a
year ago and her last flu shot was 5 to 6 years ago. She stated
taking tetracycline for her acne when she was in high school
and her skin has been better since then. MS Jones strives to
maintain safety in everything she does and ensure she live a
healthy productive life.
N/A
Family History
Ms Jones is overweight. She does have a sister who is 15 years
old and has asthma under control , Ms. Jones father died when 2
and half years ago in a car accident he was 58 years old, he had
High blood pressure , high cholesterol , and diabetes. Her
mother is 50 years old she does have high cholesterol and high
blood sugar . Paternal grandfather is 82 also with high
cholesterol and high blood pressure, maternal grandfather dies
of heart attack at the age of 80 he also had high cholesterol and
high blood pressure. The maternal grand mother died of colon
cancer when she was 73 and also had the high cholesterol and
high blood pressure.
N/A
Social History
Ms Jones has never married, but she currently has a boyfriend
and they are to have sex. She lives with her sister and her
mother since her father died. She is about to move to her own
place.MS jones recently graduated and stated having a good
relationship with her family , occasionally goes swimming with
friend, goes to church , uses diet coke as source of caffeine ,
does not smoke cigarettes and drinks alcohol socially no more
that 2 drinks. She does not use recreational drugs. She used
marijuana in the past it has been 6 years since,
N/A
Mental Health History
Ms. Jones stated not being depressed , currently exicted about
her new job, never had suicidal ideations , expressed getting
stressed in the past by school.

N/A
Review of Systems - General
High blood glucose about 5 month ago. Has not had fevers,
chills or night sweats. recently some weight lost but not
willingly. No headaches , no nausea.
N/A
HEENT
Model Documentation
Subjective
Reports t have had headaches in the past, specially related to
school work, she has not had headache for while , no pain , not
itchiness on ayes or ears , sinuses clear , sense of smell intact ,
hearing intact , she does got glasses for eyesight like 3 months
ago, does not have problems with throat, no soreness or dryness
reported or seen , no difficultly swallowing or breathing
N/A
Objective
Head normocephalic no traumatic lesion noted, symmetric ears,
no drainage , nares pink and moist , eyelids symmetric no
swelling . vision 20/20 with glasses, conjunctiva pink ,hearing
is intact. PERRLA . Gag reflex intact. Eye lids upper and lower
symmetric , pink and moist. Internal bilateral ears pearly gray,
JAw with appropriate movement no clicks . No masses on the
scalp . No palpable nodes in the neck . No Nodules or goiter
palpated in the thyroid. No pain reported in the sinus , no
axillary nodes palpable. Intra ocular movement intact. Vision
intact
N/A
Respiratory
Model Documentation
Subjective
Does not have problems breathing, does not report cough or
chest pain
N/A

Objective
Her chest is symmetric with even and unlabored respirations
present to auscultation bilaterally. resonant percussion
throughout . FVC1.78 L, FEV11,54 . Posterior chest wall
resonant bilaterally. Thoracic expansion symmetric
N/A
Cardiovascular
Model Documentation
Subjective
Does not report any issues with heart or beathing , denies chest
pain
N/A
Objective
S1 and S2 noted , no murmurs or gallops . PMI at midclavicular
line 5th intercostal , no haves , thrills lifts. Has bilateral carotid
without bruit, bilateral peripheral pulses present equally.
Capillary refill less that 3 seconds. No lower leg edema
bilaterally . Bilateral right and left brachial pulses present +2,
lower peripheral pulses present +2, right ankle left carotid +2
no thrill , auscultated no bruit bilaterally , abdominal arteries no
bruit
N/A
Abdominal
Model Documentation
Subjective
Does not report diarrhea or issued with the abdomen , no GERT,
no dysuria , no vaginal itching does not feel boated does not
experience nausea or vomiting
N/A
Objective
Abdomen is symmetric and protuberant , no scars , masses or
lesions. Hair from pubis and the umbilicus is coarse , bowel
sounds normoactive present in all quadrants. No organomegaly ,
CVA or tenderness noted. Liver 1 cm below right costal margin

, no palpated kidneys or masses , not palpable spleen .
Percussed liver span 7 MCL on percussion. CVA tenderness or
right none reported
N/A
Musculoskeletal
Model Documentation
Subjective
reports no pain in the shoulder, arms , muscle or joint. HAd
some back pain some weeks ago when she helped a friend carry
heavy items when she was moving , she does not have back pain
presently, no swelling
N/A
Objective
Upper and lower extremities all have 5/5 strength no masses or
swelling , no noted deformities , full range of motion in all
extremities
N/A
Neurological
Model Documentation
Subjective
Alert and oriented times 4 , no light headedness or loss of
balance reported the coordination is intact , speech is intact
N/A
Objective
Cerebral function intact upon assessment , good memory ,
graphesthesia intact with appropriate alternating movements
bilaterally. DTRs 2 + and equal bilaterally
N/A
Skin, Hair & Nails
Model Documentation
Subjective
Has acne when was young at high school , it stopped with the
use of medication. Zits present usually managed by birth control

pills
N/A
Objective
Scattered pustules on the face and facial hair on upper lip. Has
acanthosis nigricans on the neck . Nails appropriate no
abnormalities noted
N/A
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:

Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:.
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:

PLAN: This section is not required for the assignments in this
course (NURS 6512), but will be required for future courses.
© 2021 Walden University, LLC
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1Week 9 Patient Comprehensive ExamWalden Universit

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