2024-2025 SOAP NOTE Shadow Health Clinic Comprehensive Assessment (1 Solved Case)

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SOAPNOTE–ComprehensiveAssessment–TinaJones–ShadowHealthClinic–RyanKent2024/2025VERIFIED ANSWERSSUBJECTIVE:Chiefcomplaint(CC):“IcameinbecauseI'mrequiredtohavearecentphysicalexamforthehealthinsurance atmy newjob.”History of present illness (HPI): Ms. Jones reports that she recently obtained employment atSmith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physicalprior to initiating employment. Today she denies any acute concerns. Her last healthcare visitwas 4 months ago, when she received her annual gynecological exam at Shadow HealthGeneral Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovariansyndrome andprescribed oral contraceptives at that visit, which she is tolerating well. She hastype 2 diabetes, which she is controlling with diet, exercise, and metformin, which she juststarted5monthsago.Shehasnomedicationsideeffectsatthistime.Shestatesthatshefeelshealthy, is taking better care of herself than in the past, and is looking forward to beginning thenewjob.Allergies:•Penicillin:rash•Deniesfoodandlatexallergies•Allergic to cats and dust. When she is exposed to allergens shestates that she has runnynose, itchyand swolleneyes,andincreased asthmasymptoms.Past medical history (PMH): Asthma diagnosed at age 2 1/2. She uses her albuterol inhalerwhen she is around cats. Her last asthma exacerbation was three months ago, which sheresolvedwithherinhaler.Shewaslasthospitalizedforasthmainhighschool.Neverintubated.Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially hadsome gastrointestinal side effects which have since dissipated.She monitors her blood sugaronce daily in the morning with average readings being around 90. She has a history ofhypertension 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 moderatebleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to

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