Medical Assessment SOAP Note
History & Physical Format
IDENTIFICATION:
Date: 20/09/2021 Time: 09:45 am
Name: J.D.R Sex: F Race: Caucasian
Marital status: Married
Address: Miami.FL
Tel. #: 345-789-1234
DOB: 26/03/1981
SUBJECTIVE:
CHIEF COMPLAINT (CC): “Annual physical exam”
HISTORY OF PRESENT ILLNESS (HPI): The patient is a 40-year-old female who comes in today for annual health maintenance and routine physical. Her last physical was last year. She just had a Pap recently. She states that she has a couple of different problems that she would like to address.
One is that she has had a lot of gas pain, and it is very uncomfortable. She is bloated often times. She has not been eating regularly, but she has noticed that her belly swells a lot. Lately, she has been a little dizzy and lightheaded. She will get very lightheaded and she will start to have a little shakes. Has fainted a couple of times.
Another problem is heartburn. She said that she has had some heartburn. The patient has a little shortness of breath and some shooting pain; it lasts for a minute or so, and it is especially on the left side.
PAST MEDICAL HISTORY (PMH): Unremarkable. The patient does have mitral valve prolapse.
FAMILY HISTORY (FH): A paternal aunt was recently diagnosed with breast cancer at age 50. Her father is healthy. Her mother is healthy.
SOCIAL HISTORY (SH): The patient does not smoke, does not drink alcohol.
REVIEW OF SYSTEMS (ROS): Denies any palpitation. Does have occasional shortness of breath with the shooting pain running across her chest, no real chest pain per se. No migraine headaches. Sometimes constipated, but no diarrhea, mostly no blood in her stools. No musculoskeletal pain, no headaches. Review of systems basically noncontributory.
ALLERGIES: No known allergies.
MEDICATIONS: TriNessa.
HEALTH MAINTENANCE: The patient does exercise all the time. She is very active. She does wear her seat belt. She does use sunscreen. Her last Pap was on 10/07/2020. Her last period was 08/29/2021. She has never had a STD. Never had any abuse or any domestic violence.
OBJETIVE:
GENERAL: The patient is a pleasant female, in no acute distress. Well developed, well nourished. VITAL SIGNS: The patient is 170 cm tall. She weighs 140 pounds. Her blood pressure is 110/70.
HEENT: Head is normocephalic and atraumatic. Pupils are equal and reactive to light with good red light reflex. TMs are pearly gray, clear, with good cone of light reflex. Nasal mucosa is pink. Oropharynx is pink. No exudate Dentition is good. NECK: Supple. No lymphadenopathy noted. No carotid bruits. No thyroid mass or thyromegaly. LUNGS: CTAP bilaterally. No wheezes, rales or rhonchi. HEART: Well-beaten, rhythmic heart sounds, not murmurs. Normal S1 and S2. . There are no lifts, heaves or thrills noted on palpation. EXTREMITIES: Upper and Lower extremities without CCE. GENITOURINARY: EGBUS normal. Denies dysuria, urgency, discharge or bleeding currently.
SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor.
RECTAL: Normal sphincter tone. No masses or tenderness.
NEUROLOGIC: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through XII are intact. Deep tendon reflexes are intact. PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Appropriate mood and affect.
ASSESSMENT:
1. Gas pain, abdomen bloated and constipation ---- SUGGESTED of Irritable bowel syndrome with constipation (K58.1).
2. Dizziness and a question of fainting ---- SUGGESTED of Hypoglycemia (E16.2)
3. Shortness of breath and shooting pain – SUGGESTED of Nonrheumatic mitral (valve) prolapse (I34.1)
PLAN:
1. We did postural blood pressures, and they were perfectly fine. She does not have postural hypertension. Also, do 24-hour urine for catecholamines to rule out any adrenal problems or thrombocytosis.
2. Will get a stress test and do an echocardiogram to rule out any abnormalities, for the patient’s shortness of breath and shooting pain because of her mitral valve prolapse.
3. Omeprazole (40mg) every 12 hours and Mylanta II after each meal for the patient’s heartburn and gas pains, she does have to eat healthy.
4. Increase fiber intake and Metamucil (0.4g Cap) 2 times a day for the patient´s constipation.
5. The patient has dizziness and a question of fainting. Most likely, it could be a questions of hypoglycemia. We will do a glucose tolerance test to rule out that and also we will do blood work.
6. She will try to eat six small meals a day. She does have to eat, and we do not think she has enough of food in her system post all the exercise that she does do.
7. We will follow up with the results by a letter or by phone call.