Rwh 2 soaps wk 5

SOAP Note _______

NU___:_________

Herzing University

Name:_________________________

Typhon Encounter #: _____________________

Comprehensive:____Focused:____

S: SUBJECTIVE DATA

CC:

“Just here for my yearly check-up. I’ve been feeling okay but tired lately.”

HPI:

41-year-old Hispanic female presents for annual well-person exam. Reports increased fatigue over past 3 months.

· O (Onset): 3 months ago

· L (Location): Generalized

· D (Duration): Persistent

· C (Characteristics): General lack of energy, worse in afternoons

· A (Associated/Aggravating factors): None identified

· R (Relieving factors): Rest mildly improves symptoms

· T (Treatment tried): None

· S (Summary): Fatigue is primary concern beyond routine check-up; no associated chest pain, shortness of breath, mood changes, appetite or weight changes.

PMH:

· Essential (primary) hypertension, diagnosed 2018, managed with medication.

· No surgeries, hospitalizations, or other chronic conditions reported.

ALLERGIES

· Drug: none

· Food: None

· Environmental: None

MEDICATIONS

· Lisinopril 10 mg, PO, daily – hypertension (#30, 3 refills)

· Hydrochlorothiazide 25 mg, PO, daily – hypertension (#30, 3 refills)

· Multivitamin, PO, daily – general health (#30, 3 refills)

SH

· Lives with husband and two children; works as administrative assistant.

· Denies tobacco or illicit drug use; drinks alcohol socially (1–2 drinks/week).

· Moderate work stress; no significant financial/social concerns.

· Sexually active with one male partner; uses condoms.

· Sleeps 6–7 hrs/night; drinks 1–2 cups coffee daily.

· Catholic; no health-related restrictions.

· Primary language: English.

FH

· Maternal: Hypertension (diagnosed at 50).

· Paternal: Type 2 diabetes (diagnosed at 55).

· Maternal mother: Unknown

· Maternal father: Unknown

· Paternal mother: Unknown

· Paternal father: Unknown

· Siblings: Unknown

HEALTH PROMOTION & MAINTENANCE

· Immunizations

· Influenza – 1 dose (2024)

· Tdap (Tetanus, Diphtheria, Pertussis) – 1 dose (2020)

· HPV (Human Papillomavirus) – Complete series (dates unknown)

· COVID-19 – Unknown

· MMR (Measles, Mumps, Rubella) – Unknown

· Varicella (Chickenpox) – Unknown

· Hepatitis A – Unknown

· Hepatitis B – Unknown

· Meningococcal (MenACWY / MenB) – Unknown

· Pneumococcal (PCV15/PCV20 or PPSV23) – Unknown

· Zoster (Shingles) – Unknown

· Polio (IPV) – Unknown

· Haemophilus influenzae type b (Hib) – Unknown

· Diet: Balanced, occasional fast food.

· Exercise: Walks 20 min, 3–4x/week.

· Mammogram: 2024 (normal)

· Pap smear: 2023 (normal)

· Colonoscopy: Not yet (due at age 45).

· Dental exam: 6 months ago.

· Eye exam: 1 year ago; wears glasses for reading.

ROS

(put N/A in sections not completed day of exam)

Constitutional

Fatigue; denies fever, chills, weight change.

Head

No headaches or dizziness.

Eyes

No vision changes; wears reading glasses.

Ears, Nose, Mouth, Throat

No hearing loss, congestion, sore throat.

Neck

No stiffness or pain.

Cardiovascular/Peripheral Vascular

No chest pain, palpitations, edema.

Respiratory

No shortness of breath or cough.

Breast

No lumps, pain, discharge.

Gastrointestinal

No nausea, vomiting, abdominal pain.

Genitourinary

No dysuria, frequency, abnormal bleeding.

Musculoskeletal

No joint pain or stiffness.

Integumentary

No rashes or lesions.

Neurological

No numbness, tingling, weakness.

Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)

No depression or anxiety (GAD-7 = 2, minimal).

Endocrine

No heat/cold intolerance, polyuria, polydipsia.

Hematologic/Lymphatic

No bruising, swollen nodes.

Allergic/Immunologic

No seasonal allergies.

Other

N/A

O: OBJECTIVE DATA

VITALS:

HR: 72 bpm

RR: 16 breaths/min

BP: 128/82 mmHg

Temp: 98.6°F

SpO2%: 98%

Ht: 5’4”

Wt: 145 lbs

BMI: 24.9

Age: 41

LMP: 2 weeks ago.

PAIN: 0/10

PHYSICAL EXAM

General Appearance

Well-appearing, alert, oriented, NAD.

Head

Normocephalic, atraumatic.

Eyes

PERRLA, no conjunctival injection.

ENT, Mouth

TMs clear, oral mucosa moist, no pharyngeal erythema.

Neck

Supple, no lymphadenopathy or thyromegaly.

Cardiovascular/Peripheral Vascular

Regular rate/rhythm, no murmurs, 2+ pulses bilaterally, no edema.

Respiratory

Clear bilaterally, no wheezing/crackles.

Breast

No masses, tenderness, skin changes.

Gastrointestinal

Soft, non-tender, non-distended, normal BS.

Genitourinary Male

· External Exam

Normal genitalia, no lesions.

· Internal Exam

Cervix normal, no CMT, uterus normal size/position.

Genitourinary Female

· External Exam

N/A

· Internal Exam

N/A

Musculoskeletal

Full ROM, no tenderness/deformities.

Integumentary

Skin warm, dry, no lesions/rashes.

Neurological

CN II–XII intact, normal gait, no tremors.

Psychiatric

Appropriate affect, no distress.

Endocrine

No goiter, no abnormal masses.

Hematologic/Lymphatic

No bruising, no adenopathy.

Allergic/Immunologic

No reaction signs.

Other

N/A

A: ASSESSMENT AND DIAGNOSIS

DIAGNOSIS

ICD-10 CODES

PRIORITIZE DIAGNOSIS

1. Essential (primary) hypertension

I10

2. Encounter for general adult medical exam without abnormal findings

Z00.00

3. Fatigue, unspecified

R53.83

VISIT CODES

CPT BILLING CODES

99396 – Periodic comprehensive preventive medicine E&M, established patient, 40–64 yr

DIAGNOSTICS

POC TESTING

None today.

TESTS REVIEWED

None; new labs ordered.

P: PLAN

ACTIONS

1.

Diagnosis: Essential (primary) hypertension

Diagnostics Order: CMP, lipid panel, TSH.

Therapeutic: Continue Lisinopril 10 mg PO daily (#30, 3 refills), Hydrochlorothiazide 25 mg PO daily (#30, 3 refills).

Education: Medication adherence, low-sodium diet, regular exercise, home BP monitoring.

Consultation/Collaboration: None now; consider cardiology if uncontrolled

2.

Diagnosis: Encounter for general adult medical exam without abnormal findings

Diagnostics Order: Pap smear (due), mammogram (due 2026).

Therapeutic: Continue multivitamin PO daily (#30, 3 refills).

Education: USPSTF screening guidance, colorectal screening due at 45, exercise 150 min/week, balanced diet.

Consultation/Collaboration: None.

3.

Diagnosis: Fatigue, unspecified

Diagnostics Order: CBC, TSH, CMP.

Therapeutic: None pending labs.

Education: Sleep hygiene, stress management, increase exercise, symptom monitoring.

Consultation/Collaboration: Consider sleep study if persists and labs normal.

PREVENTITIVE

· Annual flu vaccine; maintain immunizations.

· Breast cancer screening q2y, cervical cancer screening q3y, colorectal at 45.

· Limit alcohol to 1 drink/day, maintain healthy weight, stress reduction.

FOLLOW UP

Return in 3 months for labs/BP check, sooner if symptoms worsen.