Miami Regional University Date Of Encounter Preceptor Clinic

miami Regional Universitydate Of Encounterpreceptorclinical Sitecl

1 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: He has no history of hospitalizations. Denies chronic illnesses such as cancer, HTN, psychiatric diseases, asthma, or diabetes. Immunizations: COVID 19 vaccine on 10/12/2021. He received the influenza vaccine on 5/2021. Tdap booster was given in 2010. He received all childhood immunizations but was unable to recall the exact dates. Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021 Surgical History: No history of recent or previous surgeries. 2 Family History: Raised by biological parents. His mother is 78years and has HTN and diabetes. Father is 85 years with no chronic illness. His maternal grandfather died at 80 years and had a history of BPH and HTN. Social History: He is a small-scale farmer. Married to one wife. Has three children. He neither smokes nor drinks. Sexual Orientation: He has one wife, and he is heterosexual Nutrition History: He takes a balanced diet. He avoids fat-rich diets and processed foods. He takes a fruit every day in the morning. He drinks seven glasses of water every day. He does not drink sweetened drinks or coffee. Subjective Data: Chief Complaint: "I am feeling great, but I am here for my annual check-up." Symptom analysis/HPI: The patient's last annual check-up was in May 2021. The patient reports the absence of any abnormal laboratory or physical findings during that check-up. His previous eye examination was on October 2021. His last dental review was in November 2021. Colonoscopy and PSA test were done in January 2018. His previous B.P. screening, Blood Sugar Screening were done in March 2021. Lip profile tests were done in January 2017. There were no other current concerns or complaints by the patient. Review of Systems (ROS) CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever RESPIRATORY: No dyspnea, wheezing, chest pains, or cough GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion HEENT: No dizziness, headache, or confusion. Eyes: no itching, pain, diplopia, or blurry vision Ears: no pain, hearing loss, tingling sensation, or discharges Nose: No bleeding, itching, or discharge Throat: no sore throat, edema, or voice changes CARDIOVASCULAR: no chest pains, palpitations, dizziness, or edema GENITOURINARY: no dysuria, discharge, urinary urgency, or hematuria MUSCULOSKELETAL: no muscle pains, joint swelling, joint pain, or muscle spasms SKIN: no hives, skin rashes, or hyperpigmentation Objective Data: VITAL SIGNS: BP-110/90 mmHg, RR 19, Pulse rate 70b/min. SpO2 is 100%. Height-180cm, Weight-63kg, computed BMI-22.5 GENERAL APPEARANCE: A white male, seated, alert and well-nourished, with no signs of respiratory distress. There is no pallor, jaundice, cyanosis, dehydration, edema, or lymphadenopathy. NEUROLOGICAL: Normal speech, Alert & oriented x3, typical gait, no tremors, no cerebellar signs, or motor-sensory loss. RESPIRATORY: Chest wall is symmetrical, rises following respiration, no visible masses or scars, no tenderness, percussion note is tympanic, bilateral entry of air, breath sounds were normal following auscultation. CARDIOVASCULAR: Normoactive precordium, palpable apical pulse mid-clavicular line at the 5th ICS, regular HR, no thrills, no heaves, on auscultation, no murmurs, S1 and S2 heard clearly. GASTROINTESTINAL: Flat abdomen, umbilicus everted, moving with respiration, no masses, tenderness or organomegaly; warm, normoactive bowel sounds. INTEGUMENTARY: Dark, warm, and dry. No rashes, abrasions, lesions, or hives. HEENT: Normocephalic, no scars, masses or bruises. Pupils equal, round, reactive to light, no discharges. No ear discharges or impacted wax. Nares patent, no discharge or bleeding. Neck: No distended veins, lymphadenopathy, or swelling; supple. MUSCULOSKELETAL: No abnormalities, normal gait, normal reflexes, no deformities, and full ROM. ASSESSMENT: A 55-year-old male, S.N. is here for routine annual health check-up with no current complaints and normal past screening results. His physical examination shows no abnormalities. The primary diagnosis is an annual wellness checkup with no abnormal findings (ICD Z00.00). Plan includes necessary screenings and preventive measures based on age and risk factors. Preventative Care and Screening Recommendations: The use of evidence-based practices such as PSA screening, colonoscopy, updating immunizations, blood pressure, blood sugar, and lipid profile testing to facilitate early detection of common conditions in men aged 55. The patient’s family history of HTN, diabetes, and BPH warrants continued screening and health education (CDC, 2020; Catalona, 2018; Saito et al., 2021). The patient is advised to maintain a healthy diet, regular exercise, and hydration, with follow-up scheduled to review test results and discuss further health management steps. Overall, this comprehensive approach aligns with current clinical guidelines for preventive care (Carey et al., 2018; Vijan & Elmore, 2020). References include CDC guidelines, recent research articles on prostate cancer screening, cardiovascular risk assessments, and updates from authoritative sources on immunizations and screenings (Hibberd, 2020; Saito et al., 2021; Vijan & Elmore, 2020).