Miami Regional University Date Of Encounter Preceptor 093279

miami Regional Universitydate Of Encounterpreceptorclinical Sitecl

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, 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 and oriented x3, typical gait, no tremors, no cerebellar signs or motor-sensory loss. RESPIRATORY: Chest wall symmetrical, normal breath sounds, no tenderness or masses. CARDIOVASCULAR: Regular HR, palpable apical impulse at 5th ICS, no murmurs. GASTROINTESTINAL: Flat abdomen, everted umbilicus, no masses or tenderness, normal bowel sounds. INTEGUMENTARY: Dark, warm, dry skin, no rashes or lesions. HEENT: Normocephalic, pupils equal and reactive, no discharges, nasal patency intact, no lymphadenopathy. NECK: no distension or lymphadenopathy, supple. MUSCULOSKELETAL: Normal gait, ROM, no deformities.

Assessment: The patient is a 55-year-old male presenting for his annual wellness check-up with no current complaints. Past screening and examination findings are unremarkable. Family history includes hypertension and BPH, increasing his risk factors for these conditions. On physical exam, no abnormalities noted. Main Diagnosis -1: ICD Z00.00 - Annual checkup with no abnormal findings.

Plan: The patient will undergo routine screening tests including PSA, colonoscopy, blood pressure, blood sugar, and lipid profile, aligned with CDC guidelines and preventive health recommendations (CDC, 2020; Catalona, 2018; Saito et al., 2021; Vijan & Elmore, 2020). Investigations: CBC, urinalysis, UECs, lipid panel, ECG, echocardiogram, renal function tests, and TSH. Educate the patient on maintaining healthy lifestyle habits: regular exercise, balanced diet rich in fruits and vegetables, maintaining hydration, and avoiding smoking and excessive alcohol intake. Advise adherence to scheduled screenings and immunizations; ensure Tdap booster and update immunizations as needed (Hibberd, 2020). Follow-up: Re-assess lab results in one week, with continued monitoring and scheduled next annual visit for January 2023; patient advised to return sooner if symptoms develop.

References

• Centers for Disease Control and Prevention. (2020). Adult immunization schedule by vaccine and age group. CDC. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html
• Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 341-355.
• Saito, Y., Oka, S., Kawamura, T., et al. (2021). Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 615-624.
• Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate. Waltham, MA.
• Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. https://www.uptodate.com/contents/tetanus-diphtheria-vaccine-in-adults
• Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee. (2018). Prevention, detection, evaluation, and management of high blood pressure in adults. Annals of Internal Medicine, 168(5), 351–358.
• American College of Cardiology/American Heart Association. (2017). Hypertension guidelines update. Journal of the American College of Cardiology, 70(4), 464-471.
• Saito, Y., Oka, S., Kawamura, T., et al. (2021). Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 615-624.
• Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate.
• Centers for Disease Control and Prevention. (2020). Recommendations for adult immunizations. CDC. https://www.cdc.gov/vaccines/adults/recommendations.html