Soap Note 1: “ADULT” Wellness Check-up
Introduction
In this soap note, we will discuss a wellness check-up for an adult patient. This particular soap note template is specifically designed to adhere to the American Psychological Association (APA) format and requires a minimum of two scholarly citations. While it is permissible to use sample templates, it is important to ensure that the Patient History, Chief Complaint (CC), History of Present Illness (HPI), Assessment, and Plan sections are personalized and created independently for the hypothetical patient. The purpose of this soap note is to demonstrate clinical skills and knowledge acquired during the course of study.
Patient History
Name: John Doe
Age: 40
Sex: Male
Date of visit: [Date]
CC (Chief Complaint)
The patient presents for a routine wellness check-up.
HPI (History of Present Illness)
John Doe is a 40-year-old male who reports no significant health concerns at the moment. He states that he has been relatively healthy and has not experienced any major illnesses in the past year. He has a sedentary lifestyle due to his office job, but he tries to exercise at least three times a week for 30 minutes. Mr. Doe reports a balanced diet with no major dietary restrictions.
Review of Systems
Constitutional: No weight loss or weight gain, no fevers, chills, or night sweats.
Integumentary: No rashes, lesions, or ecchymosis.
Cardiovascular: No chest pain, palpitations, edema, or dyspnea on exertion.
Respiratory: No cough, sputum production, wheezing, or shortness of breath.
Gastrointestinal: No abdominal pain, nausea, vomiting, or changes in bowel habits.
Genitourinary: No difficulty urinating, blood in urine, or urinary frequency.
Musculoskeletal: No joint pain, stiffness, or swelling.
Neurological: No headaches, numbness, or tingling sensations.
Psychiatric: No history of anxiety, depression, or other mental health conditions.
Endocrine: No abnormal thirst, excessive sweating, or changes in weight.
Hematologic: No easy bleeding or bruising.
Allergic/Immunologic: No history of allergies or recurring infections.
Medications
John Doe reports no current medications or supplements.
Allergies
Mr. Doe denies any known allergies to medications, foods, or environmental substances.
Family History
Father: Deceased at age 65 due to myocardial infarction.
Mother: Alive, with a history of hypertension and osteoporosis.
Sibling(s): One brother with no known medical conditions.
Current Health Maintenance
– Flu vaccination: Up-to-date
– Tetanus shot: Updated every 10 years
– Colonoscopy: None
– Mammogram: None
– PSA (Prostate-Specific Antigen) screening: None
– Pap smear: None
– Blood pressure check: Last checked six months ago, within normal range
– Cholesterol check: Last checked one year ago, within normal range
– Blood glucose check: Last checked one year ago, within normal range
– Vision and hearing exams: Last examined one year ago, no significant changes
Social History
Mr. Doe is married and lives with his wife and two children. He is employed as a project manager at a software company and works 40 hours per week. He denies tobacco smoking or alcohol use. He reports occasional social drinking on special occasions, with an average of one drink per week. He does not use recreational drugs.
Diet and Exercise
Mr. Doe describes his diet as balanced, incorporating fruits, vegetables, lean proteins, and whole grains. He tries to limit his intake of processed foods and sweets. He has no known dietary restrictions. His exercise routine consists of cardio exercises, such as running or cycling, three times a week for 30 minutes. He acknowledges his sedentary lifestyle due to his desk job and makes a conscious effort to engage in physical activity.
Conclusion
This soap note discussed the details of an adult wellness check-up for John Doe, a 40-year-old male. The patient reported no significant health concerns and exhibited a balanced lifestyle in terms of diet and exercise. The patient’s medical history, family history, and current health maintenance were also reviewed. Providing a thorough evaluation is essential for accurate assessment and planning in order to ensure the patient’s continued well-being and prevent any potential health issues.
