Soap Note Adult Wellness Checkup 10 Points Follow The Mru So

Soap Note Adult Wellness Check Up10 Pointsfollow The Mru Soap Note

Follow the MRU Soap Note Rubric as a guide: Use APA format and must include a minimum of 2 scholarly citations. Soap notes will be uploaded to Moodle and put through Turnitin. Turnitin’s score must be less than 21% to be accepted for credit; it must be your own work and in your own words. Copy-paste from websites or textbooks will not be accepted or tolerated and will receive a grade of 0 (zero) with no resubmissions allowed. Keep the sample templates for your soap note; ensure that the Patient History, Chief Complaint, HPI, Assessment, and Plan are individualized for your made-up patient. Use the provided resources for creating SOAP notes and understanding wellness visits.

Paper For Above instruction

This paper presents a comprehensive adult wellness check-up, utilizing the SOAP note format guided by the MRU rubric. The focus is on a 55-year-old male patient, S.N., who presents for his annual health assessment with no current complaints but with a proactive approach toward health maintenance and disease prevention. The evaluation encompasses detailed subjective, objective, assessment, and planning components, informed by current evidence-based guidelines and clinical practices.

Introduction

Adult wellness check-ups are fundamental components of preventive medicine, aiming to detect risk factors and prevent the development of chronic diseases. This comprehensive evaluation includes taking a detailed health history, performing physical examinations, and ordering appropriate screening tests consistent with the patient’s age, family history, and risk factors (US Preventive Services Task Force [USPSTF], 2021). The American Academy of Family Physicians (AAFP) recommends annual check-ups, emphasizing personalized assessments tailored to individual health profiles (Fowler & Baker, 2020). This SOAP note exemplifies clinical reasoning and evidence-based strategies to promote optimal health outcomes for middle-aged adults.

Subjective Data

The patient, S.N., a 55-year-old male, reports feeling generally well and states, "I am feeling great, but I am here for my annual check-up." His last comprehensive check-up was in May of 2021, with no abnormal laboratory or physical findings. He denies current symptoms such as fatigue, weight changes, or pain. The review of systems confirms absence of constitutional symptoms (fever, chills), respiratory issues (dyspnea, cough), gastrointestinal discomfort (nausea, abdominal pain), neurological deficits (numbness, confusion), or musculoskeletal complaints. His past medical history is notable for no chronic illnesses or hospitalizations. He has received all childhood immunizations and was vaccinated for COVID-19 in October 2021. His current medications include no herbal or supplement use. Family history reveals his mother, aged 78, with hypertension and diabetes, and his father, aged 85, with no significant illnesses. His maternal grandfather had hypertension and BPH. Socially, he is a small-scale farmer, married, with three children, and reports no smoking or alcohol use. He maintains a balanced diet, consumes fruits daily, drinks seven glasses of water, and avoids processed foods and added sugars.

Review of Systems (ROS)

  • Constitutional: No fatigue, chills, malaise, or fever.
  • Respiratory: No shortness of breath, wheezing, cough, or chest pain.
  • Gastrointestinal: No nausea, vomiting, diarrhea, or abdominal pain.
  • Neurological: No numbness, dizziness, or loss of consciousness.
  • HEENT: No dizziness, headache, visual disturbances, or ear pain.
  • Cardiovascular: No chest pain, palpitations, or edema.
  • Genitourinary: No dysuria, hematuria, or urinary issues.
  • Musculoskeletal: No joint pain or muscle weakness.
  • Skin: No rashes, rashes, or skin lesions.

Objective Data

Vital signs measured include blood pressure (110/90 mmHg), pulse (70 bpm), respiratory rate (19 breaths/min), oxygen saturation (100%), height (180 cm), weight (63 kg), with a calculated BMI of 22.5, indicating a normal weight. General appearance is alert, well-nourished, without signs of distress. Physical examination reveals:

  • Head: Normocephalic, atraumatic.
  • Eyes: Pupils equal, reactive to light; no erythema or discharge.
  • Ears: No discharge; auditory canal clear.
  • Nose: Patent nares, no congestion.
  • Throat: No lesions or erythema.
  • Neck: Supple, no lymphadenopathy or thyromegaly.
  • Cardiovascular: Regular heart rhythm, S1 and S2 intact, no murmurs, thrills, or heaves.
  • Respiratory: Symmetrical chest rising, clear breath sounds bilaterally, no adventitious sounds.
  • Abdomen: Flat, soft, non-tender, no hepatosplenomegaly or masses, normal bowel sounds.
  • Skin: Warm, dry, no rashes or lesions.
  • Extremities: No edema or deformities; peripheral pulses palpable.
  • Neurological: Oriented x3, normal gait, no tremors or motor deficits.

Assessment

The overall assessment indicates a healthy 55-year-old male with no current complaints. Routine screening and health maintenance are the priorities. Diagnoses include:

  1. Z00.00 – Encounter for general adult medical examination without abnormal findings.
  2. Risk factors for prostate cancer given age and family history; screening indicated.
  3. Need for updated immunizations, including Tdap booster and age-appropriate vaccines.
  4. Screening for colon cancer via colonoscopy due to age.
  5. Blood pressure management; current readings are within normal limits but surveillance recommended.
  6. Assessment of metabolic risk factors: blood sugar and lipid profile screening.

Plan

  1. Investigations:
    • Laboratory tests: CBC, fasting blood glucose or HbA1c, lipid profile, renal function tests, TSH – supported by evidence indicating their role in early detection of common conditions (Vijan & Elmore, 2020; USPSTF, 2021).
    • Screening procedures: Colonoscopy scheduled if not done recently; PSA screening for prostate cancer initiation considering age and family history.
    • Update immunizations: Administer Tdap booster; review and update other vaccines per CDC guidelines, including influenza and COVID-19 (Hibberd, 2020).
  2. Patient Education:
    • Promote healthy lifestyle habits: balanced diet emphasizing fruits, vegetables, and lean proteins; regular exercise at least four times weekly; adequate hydration.
    • Encourage smoking cessation, moderate alcohol intake, and weight management.
    • Discuss the importance of routine screening tests and immunizations for disease prevention.
    • Advise on recognizing early symptoms of prostate, colon, or other common cancers.
  3. Referrals:
    • Schedule colonoscopy with gastroenterology.
    • Refer to urology for PSA assessment based on screening results or patient preference.
  4. Follow-up:
    • Schedule follow-up appointment in 1 week to review laboratory findings and plan further management if necessary.
    • Next annual wellness check-up scheduled for January 2023.

Conclusion

This comprehensive adult wellness assessment underscores the importance of routine preventive screening tailored to individual risk factors. The systematic approach—including detailed history, focused physical exam, appropriate laboratory and screening tests—aligns with evidence-based guidelines, emphasizing early detection and health promotion in middle-aged adults. Such proactive strategies contribute significantly to reducing morbidity and mortality associated with chronic diseases, exemplifying patient-centered care that promotes lifelong health and well-being.

References

  • Centers for Disease Control and Prevention (CDC). (2020). Adult Immunization Schedule. https://www.cdc.gov/vaccines/schedules/hcp/adult.html
  • Fowler, F. J., & Baker, D. W. (2020). Principles of adult health maintenance. JAMA, 324(24), 2490–2497.
  • Hibberd, P. L. (2020). Tetanus-diphtheria vaccination updates. UpToDate. https://www.uptodate.com
  • Saito, Y., et al. (2021). Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 422–430.
  • United States Preventive Services Task Force (USPSTF). (2021). Recommendations for preventive services in adults. https://www.uspreventiveservicestaskforce.org
  • Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders. UpToDate. https://www.uptodate.com
  • American Academy of Family Physicians (AAFP). (2020). Adult health maintenance guidelines. https://www.aafp.org
  • World Health Organization (WHO). (2018). Guidelines for adult health screenings. https://www.who.int
  • Gerard, P., & Smith, L. (2019). Evidence-based adult preventive care. New England Journal of Medicine, 380(21), 2020–2028.
  • National Comprehensive Cancer Network (NCCN). (2022). Cancer screening guidelines. https://www.nccn.org

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