Soap Note “ADULT” Wellness Check-Up 700 WORDS
SOAP Note for an Adult Wellness Check-Up
The patient is a 30-year-old female who presents for a routine wellness check-up. She reports feeling generally well and denies any acute or chronic symptoms. She says she has a history of anxiety and depression and is taking medication for both. She refuses any recent changes in her mood or medication regimen.
Blood pressure: 120/80 mmHg
Heart rate: 70 beats per minute
Respiratory rate: 14 breaths per minute
General: The patient appears well-nourished and well-hydrated. She is alert and oriented.
Head and Neck: The patient’s head is normocephalic and atraumatic. Her neck is supple without any palpable lymphadenopathy.
Lungs: Breath sounds are clear bilaterally.
Heart: Regular rate and rhythm with no murmurs, rubs, or gallops.
Abdomen: Soft and non-tender with no hepatosplenomegaly or masses.
Extremities: No cyanosis, clubbing, or oedema.
The patient presents for a routine wellness check-up and is found to be in generally good health. Her vital signs are within normal limits, and her physical exam is unremarkable. The patient’s history of anxiety and depression is noted, and she reports no recent changes in her mood or medication regimen.
Continue current medication regimen for anxiety and depression.
Schedule follow-up appointments with the patient’s primary and mental health providers as appropriate.
Discuss lifestyle modifications to promote overall health and well-being, including a balanced diet, regular exercise, and stress management techniques.
Order routine laboratory tests, including a complete blood count, comprehensive metabolic panel, and lipid panel.
The patient’s overall health appears in good standing, with no acute or chronic symptoms reported during the visit. Her vital signs are within normal limits, and her physical exam is unremarkable. The patient’s history of anxiety and depression is noted. It is important to continue her current medication regimen while scheduling follow-up appointments with her primary and mental health providers as needed.
In addition to pharmacological management, discussing lifestyle modifications with the patient is essential to promote overall health and well-being. This includes a balanced diet, regular exercise, and stress management techniques. The patient reports that she has been experiencing increased pressure at work, so specific stress management techniques may be discussed in follow-up appointments.
Routine laboratory tests, including a complete blood count, comprehensive metabolic panel, and lipid panel, are ordered to screen for any underlying conditions or abnormalities contributing to the patient’s overall health.
The patient is advised to continue her current medication regimen while incorporating healthy lifestyle modifications and scheduling follow-up appointments to ensure her well-being.