SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent-RETAKE 2021
SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent-RETAKE 2021


SOAP NOTE – Comprehensive Assessment – Tina Jones – Shadow Health Clinic – Ryan Kent


Chief complaint (CC): “I came in because I'm required to have a recent physical

exam for the health insurance at my new job.”

History of present illness (HPI): Ms. Jones reports that she recently obtained

employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a

pre-employment physical prior to initiating employment. Today she denies any

acute concerns. Her last healthcare visit was 4 months ago, when she received her

annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that

the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed

oral contraceptives at that visit, which she is tolerating well. She has type 2

diabetes, which she is controlling with diet, exercise, and metformin, which she just

started 5 months ago. She has no medication side effects at this time. She states

that she feels healthy, is taking better care of herself than in the past, and is looking

forward to beginning the new job.


•Penicillin: rash

•Denies food and latex allergies

• Allergic to cats and dust. When she is exposed to allergens she states

that she has runny nose, itchy and swollen eyes, and increased asthma


Past medical history (PMH): Asthma diagnosed at age 2 1/2. She uses her albuterol

inhaler when she is around cats. Her last asthma exacerbation was three months

ago, which she resolved with her inhaler. She was last hospitalized for asthma in

high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began

metformin 5 months ago and initially had some gastrointestinal side effects which

have since dissipated. She monitors her blood sugar once daily in the morning with

average readings being around 90. She has a history of hypertension which

normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche,

age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual.

Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four

months ago. For the past four months (after initiating Yaz) cycles regular (every 4

weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual

contact not initiated. She plans to use condoms with sexual activity. Tested

negative for HIV/AIDS and STIs four months ago.

Health Maintenance: Last Pap smear 4 months ago. Last eye exam three months

ago. Last dental exam five months ago. PPD (negative) ~2 years ago.

Immunizations: Tetanus booster was received within the past year, influenza is not

current, and human papillomavirus has not been received. She reports that she

believes she is up to date on childhood vaccines and received the meningococcal

vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car,

and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in

the home, locked in parent’s room.

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Social history:

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Category SOAP NOTE
Pages 6
Language English
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