Soap Note 1 “ADULT” Wellness check up
Follow the MRU Soap Note Rubric as a guide.
Expert Solution Preview
Introduction:
As a medical professor responsible for creating assignments and evaluating student performance in a medical college, I understand the importance of providing students with practical and real-world scenarios to enhance their learning experience. The following is a sample answer to the given content, which outlines a SOAP note assignment for an adult wellness check-up.
Answer:
Subjective:
The patient, a 45-year-old male, presented for a routine wellness check-up today. He reports feeling generally well and denies any current illness or symptoms. No significant changes in his health history, family history, or social history have been noted since his last visit.
Objective:
Vital signs:
– Blood pressure: 120/80 mmHg
– Heart rate: 78 bpm
– Respiratory rate: 16 breaths per minute
– Temperature: 37.0°C (oral)
– BMI: 25 kg/m²
General appearance:
The patient appears well and in no acute distress. He is well-groomed and cooperative during the examination.
Head, eyes, ears, nose, and throat (HEENT):
Head: Normocephalic, atraumatic.
Eyes: Pupils equal, round, and reactive to light and accommodation (PERRLA). No conjunctival injection.
Ears: Tympanic membrane intact bilaterally. No discharge or inflammation noted.
Nose: No nasal discharge or bleeding. No septal deviation.
Throat: No tonsillar enlargement or exudates. No pharyngeal erythema.
Chest/Lungs:
Clear to auscultation bilaterally with regular respiratory effort. No wheezes, crackles, or decreased breath sounds noted.
Cardiovascular:
Regular rate and rhythm. No murmurs, rubs, or gallops. Distal pulses palpable.
Abdomen:
Soft, non-tender, and non-distended. No organomegaly or masses palpated. Bowel sounds present in all quadrants.
Musculoskeletal:
Full range of motion in all major joints without tenderness or deformities noted.
Skin:
No rashes, lesions, or discoloration observed. Skin turgor normal.
Neurological:
Cranial nerves intact. No focal deficits noted. Alert and oriented to time, place, and person.
Assessment:
Based on the subjective and objective findings, the patient is in overall good health without any acute concerns or abnormalities noted during the wellness check-up.
Plan:
1. Recommend preventive measures: Encourage the patient to maintain a healthy lifestyle with regular exercise, balanced diet, and adequate sleep.
2. Vaccination: Review the patient’s immunization status and administer any recommended vaccines if needed.
3. Screening tests: Schedule routine health screenings based on age and sex, including but not limited to blood pressure checks, lipid profile, and colorectal cancer screening.
4. Discuss any necessary lifestyle modifications: If applicable, provide counseling regarding tobacco cessation, weight management, or stress reduction techniques.
5. Follow-up: Schedule a routine follow-up visit in one year for another wellness check-up and monitoring of any indicated tests.
Conclusion:
This SOAP note outlines the subjective and objective findings of a routine adult wellness check-up. The assessment concludes that the patient is in good health, and the plan includes preventive measures, vaccinations, screening tests, lifestyle modifications if necessary, and a follow-up appointment. This exercise helps students apply their knowledge and skills in a real-world scenario while emphasizing the importance of preventive healthcare practices.
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