Miami Regional University: Date Of Encounter Preceptor Clini

Miami Regional Universitydate Of Encounterpreceptorclinical Site

Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check up PATIENT INFORMATION Name S.N. Age: 55 yrs Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: Denies food, environmental, or drug allergy Current Medications: Denies use of medications. Takes no herbal medicines or supplement medications. PMH: No history of hospitalizations; denies chronic illnesses. Immunizations: COVID-19 vaccine on 10/12/2021; influenza vaccine on 5/2021; Tdap booster in 2010; all childhood immunizations received. Preventive Care: RBS on 20/3/2021; blood pressure measured on 20/3/2021. Surgical History: No surgeries. Family History: Mother (78) with HTN and diabetes; father (85) with no chronic illnesses; maternal grandfather (80) with BPH and HTN. Social History: Small-scale farmer; married; three children; no smoking or alcohol; heterosexual; balanced diet, avoids fats, processed foods, drinks water. SUBJECTIVE DATA: Chief Complaint: "I am feeling great, but I am here for my annual check-up." HPI: Last check-up in May 2021, no abnormal findings; last eye exam in October 2021; dental review in November 2021; colonoscopy and PSA in January 2018; blood pressure and blood sugar screenings in March 2021; lipid profile in January 2017. No current concerns. Review of Systems: No fatigue, chills, weakness, night sweats, fever; no respiratory or gastrointestinal symptoms; no neurologic, HEENT, cardiovascular, genitourinary, musculoskeletal, skin issues reported. OBJECTIVE DATA: Vital Signs: BP 110/90 mmHg, RR 19, Pulse 70 bpm, SpO2 100%, height 180cm, weight 63kg (BMI 22.5). General Appearance: Alert, well-nourished, no distress or skin abnormalities. Neuro: Normal speech, gait, no tremors or sensory deficits. Respiratory: Symmetrical chest movement, clear breath sounds. Cardiovascular: Regular rhythm, no murmurs. Abdomen: Flat, everted umbilicus, no masses or tenderness. Skin: Warm, dry, no rashes. HEENT: Normocephalic, pupils reactive, ears clear, nasal passages patent. Neck: No lymphadenopathy, supple. Musculoskeletal: Normal gait and ROM. ASSESSMENT: A 55-year-old male with no current complaints, previous normal check-ups, and risk factors for BPH and prostate cancer. Main diagnosis: Z00.00 - Annual wellness check-up with no abnormal findings. Plan: Routine screening and preventive care per guidelines. Investigations: CBC, urinalysis, UEC, lipid profile, ECG, ECHO, thyroid function (TSH). Education: Continue monitoring health, exercise regularly, maintain balanced diet rich in fruits and vegetables, stay hydrated. Follow-up: Return in one week for lab results review; next annual check-up scheduled for January 2023. REFERENCES:

- Centers for Disease Control and Prevention. (2020). Recommendations for Adult Immunization.

- Catalona, W. J. (2018). Prostate Cancer Screening. Medical Clinics.

- Carey, R. M., et al. (2018). Prevention, detection, evaluation, and management of high blood pressure. Annals of Internal Medicine.

- Saito, Y., et al. (2021). Colonoscopy screening and surveillance guidelines. Digestive Endoscopy.

- Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate.

- Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate.

- CDC. (2020). Recommendations for Tdap vaccination in adults.

- American Diabetes Association. (2021). Standards of Medical Care in Diabetes.

- World Health Organization. (2019). Prevention and Control of NCDs.

- National Heart, Lung, and Blood Institute. (2022). Cardiovascular Disease Prevention.