Identifying Data (5 pts):
S.N., 55-year-old male
Chief Complaint: “I am feeling great, but I am here for my annual check-up.”
Subjective Data (30 pts):
History of Present Illness (HPI):
S.N. presents for his annual wellness check-up. His last annual check-up was in May 2021 with no abnormal findings. Recent preventive care includes:
Eye examination: October 2021
Dental review: November 2021
Colonoscopy and PSA test: January 2018
Blood pressure and blood sugar screening: March 2021
Lipid profile: January 2017
Patient reports no current health concerns or complaints.
Review of Systems:
Constitutional: Denies fatigue, chills, weakness, night sweats, or fever
Respiratory: Denies dyspnea, wheezing, chest pains, or cough
Gastrointestinal: Denies nausea, abdominal pain, vomiting, or diarrhea
Neurologic: Denies numbness, loss of consciousness, tingling, or confusion
HEENT: Denies headaches, vision changes, hearing issues, or sore throat
Cardiovascular: Denies chest pains, palpitations, dizziness, or edema
Genitourinary: Denies dysuria, discharge, urinary urgency, or hematuria
Musculoskeletal: Denies muscle pains, joint swelling, joint pain, or muscle spasms
Skin: Denies hives, skin rashes, or hyperpigmentation
Past Medical History: No history of hospitalizations or chronic illnesses.
Medications: Denies use of medications, herbal medicines, or supplements.
Allergies: Denies food, environmental, or drug allergies.
Immunizations:
COVID-19 vaccine: 10/12/2021
Influenza vaccine: 5/2021
Tdap booster: 2010
All childhood immunizations received (dates unknown)
Family History:
Mother (78 years): HTN and diabetes
Father (85 years): No chronic illnesses
Maternal grandfather: Died at 80 years, history of BPH and HTN
Social History:
Occupation: Small-scale farmer
Marital status: Married with three children
Tobacco use: Non-smoker
Alcohol use: Non-drinker
Sexual orientation: Heterosexual
Nutrition: Balanced diet, avoids fat-rich and processed foods. Daily fruit intake, seven glasses of water per day. No sweetened drinks or coffee.
Objective Data (25 pts):
Vital Signs:
BP: 110/90 mmHg
RR: 19 breaths/min
Pulse: 70 bpm
SpO2: 100%
Height: 180 cm
Weight: 63 kg
BMI: 22.5 kg/m²
General Appearance: Well-nourished white male, alert, no signs of respiratory distress. No pallor, jaundice, cyanosis, dehydration, edema, or lymphadenopathy.
HEENT: Normocephalic, PERRLA, no ear discharges, patent nasal nares, no oral lesions.
Neck: Supple, no lymphadenopathy or JVD.
Cardiovascular: Regular rate and rhythm, S1 and S2 normal, no murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
Gastrointestinal: Soft, non-tender, non-distended. Normal bowel sounds. No organomegaly.
Musculoskeletal: Normal gait, full ROM in all joints, no deformities.
Neurological: Alert and oriented x3, cranial nerves II-XII intact, normal sensation and strength.
Skin: Warm, dry, no rashes or lesions.
Assessment (10 pts):
Z00.00 – Encounter for general adult medical examination without abnormal findings
S.N. is a 55-year-old male presenting for his annual wellness check-up. He reports no current health concerns and has no significant past medical history. However, he has family history significant for hypertension, diabetes, and benign prostatic hyperplasia, which puts him at increased risk for these conditions.
Plan (15 pts):
Preventive screenings:
PSA screening (Z12.5): Recommended annually for men over 50 (Catalona, 2018).
Colonoscopy (Z12.11): Last done in 2018, due for repeat in 5-10 years based on previous results.
Blood pressure screening (Z01.30): Continue annual monitoring.
Blood sugar screening (R73.09): Perform HbA1c test due to family history of diabetes.
Lipid profile (Z13.220): Due for repeat as last test was in 2017.
Immunizations:
Tdap booster (Z23): Due for update as last dose was in 2010. CDC recommends Td or Tdap booster every 10 years (Hibberd, 2020).
Lifestyle counseling:
Encourage continuation of healthy diet and exercise habits.
Reinforce importance of maintaining a healthy weight and BMI.
Follow-up:
Schedule next annual wellness visit in one year.
Return in 1-2 weeks for review of lab results.
References:
Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214. https://doi.org/10.1016/j.mcna.2017.11.001
Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-vaccination-in-adults
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SOAP Note
SOAP Note # 1 Main Diagnosis: Z00.00 – Encounter for general adult medical examination without abnormal findings
PATIENT INFORMATION
Name: S.N.
Age: 55 years
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: Denies food, environmental, or drug allergies
Current Medications: None. Denies use of herbal medicines or supplements.
S: SUBJECTIVE DATA
Chief Complaint: “I am feeling great, but I am here for my annual check-up.”
History of Present Illness (HPI): S.N. presents for his annual wellness check-up. His last annual check-up was in May 2021 with no abnormal findings. Recent preventive care includes eye examination (October 2021), dental review (November 2021), colonoscopy and PSA test (January 2018), blood pressure and blood sugar screening (March 2021), and lipid profile (January 2017). Patient reports no current health concerns or complaints.
Past Medical History: No history of hospitalizations. Denies chronic illnesses such as cancer, HTN, psychiatric diseases, asthma, or diabetes.
Immunizations: COVID-19 vaccine (10/12/2021), influenza vaccine (5/2021), Tdap booster (2010). All childhood immunizations received but unable to recall exact dates.
Family History: Mother (78 years) has HTN and diabetes. Father (85 years) has no chronic illnesses. Maternal grandfather died at 80 years with a history of BPH and HTN.
Social History: Small-scale farmer. Married with three children. Non-smoker, non-drinker. Heterosexual.
Review of Systems:
Constitutional: Denies fatigue, chills, weakness, night sweats, or fever
HEENT: Denies headaches, vision changes, hearing issues, or sore throat
Cardiovascular: Denies chest pains, palpitations, dizziness, or edema
Respiratory: Denies dyspnea, wheezing, chest pains, or cough
Gastrointestinal: Denies nausea, abdominal pain, vomiting, or diarrhea
Genitourinary: Denies dysuria, discharge, urinary urgency, or hematuria
Musculoskeletal: Denies muscle pains, joint swelling, joint pain, or muscle spasms
Neurologic: Denies numbness, loss of consciousness, tingling, or confusion
Skin: Denies hives, skin rashes, or hyperpigmentation
O: OBJECTIVE DATA
Vital Signs: BP 110/90 mmHg, RR 19, Pulse 70 bpm, SpO2 100%, Height 180 cm, Weight 63 kg, BMI 22.5 kg/m²
General Appearance: Well-nourished white male, alert, no signs of respiratory distress. No pallor, jaundice, cyanosis, dehydration, edema, or lymphadenopathy.
HEENT: Normocephalic, PERRLA, no ear discharges, patent nasal nares, no oral lesions.
Neck: Supple, no lymphadenopathy or JVD.
Cardiovascular: Regular rate and rhythm, S1 and S2 normal, no murmurs, rubs, or gallops.
Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
Gastrointestinal: Soft, non-tender, non-distended. Normal bowel sounds. No organomegaly.
Musculoskeletal: Normal gait, full ROM in all joints, no deformities.
Neurological: Alert and oriented x3, cranial nerves II-XII intact, normal sensation and strength.
Skin: Warm, dry, no rashes or lesions.
A: ASSESSMENT
Z00.00 – Encounter for general adult medical examination without abnormal findings
S.N. is a 55-year-old male presenting for his annual wellness check-up. He reports no current health concerns and has no significant past medical history. However, he has a family history significant for hypertension, diabetes, and benign prostatic hyperplasia, which puts him at increased risk for these conditions.
The American Cancer Society recommends that men at average risk of prostate cancer should start discussing screening at age 50 (Catalona, 2018). Given S.N.’s age and family history of BPH, a PSA screening is appropriate at this time.
P: PLAN
Preventive screenings:
PSA screening (Z12.5): Order PSA test.
Colonoscopy (Z12.11): Due for repeat in 2023-2028 based on previous results.
Blood pressure screening (Z01.30): Continue annual monitoring.
Blood sugar screening (R73.09): Order HbA1c test.
Lipid profile (Z13.220): Order lipid panel.
Immunizations:
Tdap booster (Z23): Administer Tdap booster. The CDC recommends Td or Tdap booster every 10 years (Hibberd, 2020).
Lifestyle counseling:
Encourage continuation of healthy diet and exercise habits.
Reinforce importance of maintaining a healthy weight and BMI.
Follow-up:
Schedule next annual wellness visit in one year.
Return in 1-2 weeks for review of lab results.
References:
Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214. https://doi.org/10.1016/j.mcna.2017.11.001
Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-vaccination-in-adults
