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Soap Note “ADULT” Wellness check upUse APA format and must include a minimum of 2 Scholarly Citations.please will check it plagiarism (anti-Plagiarism program)Must use the sample templates for your soap note the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient. What to Expect in a Wellness Visit (YouTube Video)
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Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up
PATIENT INFORMATION
Name S.N.
Age: 55 yrs
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: Denies food, environmental, or drug allergy
Current Medications: Denies use of medications. Takes no herbal medicines or supplement
medications.
PMH: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN,
psychiatric diseases, asthma, or diabetes.
Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on
5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was
unable to recall the exact dates.
Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021
Surgical History: No history of recent or previous surgeries.
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Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes.
Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a
history of BPH and HTN.
Social History: He is a small-scale farmer. Married to one wife.Has three children. He neither
smokes nor drinks.
Sexual Orientation: He has one wife, and he is heterosexual
Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He
takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not
drink sweetened drinks or coffee.
Subjective Data:
Chief Complaint: “I am feeling great, but I am here for my annual check-up.”
Symptom analysis/HPI: The patient’s last annual check-up was in May 2021. The patient
reports the absence of any abnormal laboratory or physical findings during that check-up. His
previous eye examination was on October 2021. His last dental review was in November 2021.
Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar
Screening were done in March 2021. Lip profile tests were done in January 2017. There were no
other current concerns or complaints by the patient.
Review of Systems (ROS
CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever
RESPIRATORY: No dyspnea, wheezing, chest pains, or cough
GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea
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NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion
HEENT: H: no dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry
vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching,
or discharge o Throat: no sore throat, edema, or voice changes
CARDIOVASCULAR: no chest pains, palpitations,dizzness or edema
GENITOURINARY: no dysuria, discharge, urinary urgency, or hematuria
MUSCULOSKELETAL: no muscle pains, joint swelling, joint pain, or muscle spasms
SKIN: no hives, skin rashes, or hyperpigmentation
Objective Data:
VITAL SIGNS: BP-110/90 mmHg, RR 19, Pulse rate 70b/min . SPo2 is 100%. Height-180cm,
Weight-63kg, computed BMI-22.5
GENERAL APPEARANCE: A white male, seated, alert and well-nourished, with no signs of
respiratory distress. There is no pallor, jaundice, cyanosis, dehydration, edema, or
lymphadenopathy.
NEUROLOGICAL: Normal speechA& O x3, typical gait, no tremors, normal speech, no
cerebellar S/S, or motor-sensory loss.
RESPIRATORY: Chest wall is symmetrical, rises following respiration, no visible masses or
scars, no tenderness, percussion note is tympanic, bilateral entry of air, breath sounds were
normal following auscultation.
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CARDIOVASCULAR: Normoactive precordium, palpable apical pulse mid-clavicular line at
the 5th ICS, regular H.R., no thrills, no heaves, On auscultation, there were no murmurs, and S1
and S2 were heard.
GASTROINTESTINAL: Flat abdomen, umbilicus everted, moving with respiration, no
masses, no tenderness or organomegaly; warm. Normoactive bowel sounds were heard.
INTEGUMENTARY: Dark, warm, and dry. No rashes, abrasions, lesions, or hives
HEENT: H: Normocephalic, no scars, masses, or bruises. E: Pupils are equal, round, and
reactive to light, with no discharges. E: no ear discharges or impacted wax N: Symmetrical,
patent nasal nares, no discharge or bleeding.
Neck: No distended veins or lymphadenopathy and supple
MUSCULOSKELETAL: No abnormalities, normal gait, normal reflexes, no deformities, and
normal ROM.
ASSESSMENT:
55-year-old S.N. came to our clinical for his annual check-up. There are no current complaints.
His last yearly check-up showed no abnormal findings. His past check-ups were eye exam,
dental exam, Prostate screening, colonoscopy, lipid profile check-up, and B.P. and B.S.
screenings mother has hypertension and diabetes. His maternal grandfather had a history of
hypertension and BPH. On general and physical examination, there were no abnormal findings
noted.
Main Diagnosis
-1. ICD Z00.00- Annual checkup with no abnormal findings.
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CDC recommends the performance of routine check-ups annually and lab testing to aid in
identifying any health disorders to facilitate early medications and management (CDC,2020).
The patient requires his annual check-up this year.
Preventative Service Task Recommended Screenings:
2. PSA screening-ICD 10 –CM Z12.5. This is essential for screening for malignant cancers of the
prostate.PSA screening is vital in all men above 50 years because of the risk of developing
prostate cancer (Catalona,2018). The patient is at risk of prostate cancer or BPH because of his
old age and a positive family history of BPH.
3. Update for immunization-ICD-10-CM-Z23-which is the encounter for immunization.CDC
recommends that every adult be given a single dose of Tdap and then Td or a booster for Tdap
after ten years (Hibberd,2020). Mr. SN has his immunization updated apart from Tdap.
4. Colonoscopy- ICD 10 -CM Z12.11, which is for encounter for screening for the malignant
cancers of the colon. Colonoscopy is a requirement for individuals above 50 years as it will help
in the early diagnosis of benign or malignant lesions in the rectum or the colon (Saito et
al.,2021).
5. Blood Pressure screening-ICD 10-CM Z01.30 is the encounter for assessing blood pressure
with no abnormal findings. B.P. should be regularly checked in adults above 50 years (Carey et
al.,2018). This patient is at risk of developing HTN because of the positive family of HTN.
6. Blood Sugar Screening- ICD 10-CM R73.09, the code for the HBa1c blood test. This will help
rule out diabetes mellitus and is a requirement for people above 45 years. The patient is at risk of
developing D.M. because of the positive family history.
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7. Lipid profile Check-ICD 10-CM Z13.220 in assessing lipid metabolism errors, the cholesterol
and lipid-protein levels in the blood (Vijan & Elmore, 2020). CDC recommends that adults
above 20 years have cholesterol check-ups every five years (CDC,2020).
PLAN:
Investigations
-CBC- To investigate the white blood cell differentials, RBC, and platelet
-Urinalysis-To assess any abnormalities in the urine
-UECs-To assess the electrolytes
-Lipid tests-Helps in the assessment of the levels of LDL, cholesterol, T.G.s, and HDL
-ECG and ECHO- To assess the electrical activity of the heart and any heart disorders
-Renal function tests-To assess any kidney problems
-TSH-For assessment of any thyroid disorders.
Education
1. Continue monitoring any health changes, and for any threatening health conditions, call,911
2. Have a physical exercise plan at least exercise four times a week
3. Continue with his diet and maximize taking a balanced diet, more fruits and vegetables, and
drinking seven glasses of water daily.
Follow-ups
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Advise the patient to return to the hospital after one week to assess his laboratory
findings. He can book an appointment or make a call in case of any health issues. His next
annual check-up is to be scheduled for January 2023.
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References
Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee*.
(2018). Prevention, detection, evaluation, and management of high blood pressure in
adults: synopsis of the 2017 American College of Cardiology/American Heart
Association Hypertension Guideline. Annals of internal medicine, 168(5), 351-358.
https://doi.org/10.7326/M17-3203
Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214.
https://doi.org/10.1016/j.mcna.2017.11.001
Diphtheria, tetanus, and pertussis vaccine recommendations. (2020). Centers for Disease Control
and Prevention. Retrieved January 31, 2021, from
https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/recommendations.html
Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved
February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoidvaccination- in-adults
Saito, Y., Oka, S., Kawamura, T., Shimoda, R., Sekiguchi, M., Tamai, N., … & Inoue, H. (2021).
Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 486519. https://doi.org/10.1111/den.13972
Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate. Waltham,
MA: UpToDate. https://www.medilib.ir/uptodate/show/4553
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