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Posted: July 30th, 2023
Soap Note 1 "ADULT" Wellness check up (10 points)
Follow the MRU Soap Note Rubric as a guide:
Use APA format and must include minimum of 2 Scholarly Citations.
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Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
Turn it in' s Score must be less than 10% or will not be accepted for credit; it must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 10%. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed.
Please see College Handbook regarding Academic Misconduct Statement.
Must use the sample templates for your soap note. Keep this template for when you start clinicals.
The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.
The Comprehensive Wellness Check-Up for an Adult: A SOAP Note Analysis
Introduction:
In this SOAP note, we conduct a comprehensive wellness check-up for an adult patient to assess their overall health status. SOAP notes (Subjective, Objective, Assessment, and Plan) are vital components of a patient's medical record, providing a systematic and concise method for healthcare professionals to document patient encounters. The purpose of this wellness check-up is to identify any potential health issues, assess the patient's current well-being, and develop an appropriate plan for their continued care. All information presented in this SOAP note is entirely fictional and for educational purposes only.
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Patient Background:
Name: John Doe
Age: 40
Gender: Male
Occupation: Marketing Manager
Chief Complaint (CC): The patient presents for a routine wellness check-up and states feeling generally well.
Subjective (S):
The patient denies any specific complaints, including pain, fever, or recent illnesses. He reports having a well-balanced diet and regularly engaging in exercise. There is no history of chronic medical conditions in the family. The patient admits to occasional work-related stress but believes he manages it effectively.
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Medical History:
Hypertension (diagnosed in his father at the age of 60)
Allergic rhinitis (occasional seasonal allergies)
Medications:
None
Social History:
The patient is a non-smoker and consumes alcohol occasionally, socially. He is married and lives with his spouse and two children. He states having a strong support system and a positive work-life balance.
Objective (O):
Physical Examination:
Vital Signs:
Blood Pressure: 120/80 mmHg
Heart Rate: 72 bpm
Respiratory Rate: 16 bpm
Temperature: 98.4°F (36.9°C)
General Appearance:
The patient appears well-nourished and in no acute distress. He maintains good eye contact and is cooperative during the examination.
Skin:
The skin is intact, with no signs of lesions, rashes, or abnormalities noted. Skin turgor is normal.
Cardiovascular:
Heart sounds are regular with no murmurs or abnormal sounds. Peripheral pulses are palpable and equal bilaterally.
Respiratory:
Lung sounds are clear and equal bilaterally, with no adventitious sounds.
Abdomen:
The abdomen is soft, non-tender, and non-distended. Bowel sounds are normal in all quadrants.
Assessment (A):
Based on the patient's history and physical examination, the following assessments are made:
Overall, the patient appears to be in good health, with no acute complaints or concerning symptoms.
The patient's blood pressure falls within the normal range (120/80 mmHg), which is an essential indicator of cardiovascular health.
There are no signs of respiratory issues or abnormalities detected during the physical examination.
The patient's lifestyle choices, including a balanced diet, regular exercise, and limited alcohol intake, contribute to his overall well-being.
Plan (P):
Prevention:
Encourage the patient to continue leading a healthy lifestyle with regular exercise and a balanced diet. Advise annual influenza vaccinations and periodic health screenings.
Stress Management:
Discuss stress management techniques to cope with work-related stress effectively, such as mindfulness practices and time management strategies.
Hypertension Monitoring:
Due to a family history of hypertension, recommend regular blood pressure monitoring and follow-ups to assess for early signs of hypertension.
Allergy Management:
Provide guidance on managing allergic rhinitis symptoms during seasonal flare-ups.
Follow-Up:
Schedule a follow-up appointment in six months to reassess the patient's overall health and discuss any new concerns that may arise.
Conclusion:
This comprehensive wellness check-up for the adult patient, John Doe, indicates that he is in good health overall. The absence of acute complaints and normal vital signs are positive indicators of his well-being. By maintaining a healthy lifestyle and managing stress effectively, John can continue to promote his overall health and prevent potential health issues.
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