2024-2025 SOAP NOTE Shadow Health Clinic Comprehensive Assessment (1 Solved Case)
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SOAP NOTE –
Comprehensive Assessment –
Tina Jones – Shadow Health
Clinic – Ryan Kent 2024/2025
VERIFIED ANSWERS
SUBJECTIVE:
Chief complaint (CC): “I came in because I'm required to have a recent physical exam for the
health insurance at my new job.”
History of present illness (HPI): Ms. Jones reports that she recently obtained employment at
Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical
prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit
was 4 months ago, when she received her annual gynecological exam at Shadow Health
General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian
syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has
type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just
started 5 months ago. She has no medication side effects at this time. She states that she feels
healthy, is taking better care of herself than in the past, and is looking forward to beginning the
new job.
Allergies:
• Penicillin: rash
• Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens she states that she has runny
nose, itchy and swollen eyes, and increased asthma symptoms.
Past medical history (PMH): Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler
when she is around cats. Her last asthma exacerbation was three months ago, which she
resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated.
Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had
some gastrointestinal side effects which have since dissipated. She monitors her blood sugar
once daily in the morning with average readings being around 90. She has a history of
hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN:
Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago.
For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate
bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to
Comprehensive Assessment –
Tina Jones – Shadow Health
Clinic – Ryan Kent 2024/2025
VERIFIED ANSWERS
SUBJECTIVE:
Chief complaint (CC): “I came in because I'm required to have a recent physical exam for the
health insurance at my new job.”
History of present illness (HPI): Ms. Jones reports that she recently obtained employment at
Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical
prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit
was 4 months ago, when she received her annual gynecological exam at Shadow Health
General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian
syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has
type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just
started 5 months ago. She has no medication side effects at this time. She states that she feels
healthy, is taking better care of herself than in the past, and is looking forward to beginning the
new job.
Allergies:
• Penicillin: rash
• Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to allergens she states that she has runny
nose, itchy and swollen eyes, and increased asthma symptoms.
Past medical history (PMH): Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler
when she is around cats. Her last asthma exacerbation was three months ago, which she
resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated.
Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had
some gastrointestinal side effects which have since dissipated. She monitors her blood sugar
once daily in the morning with average readings being around 90. She has a history of
hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN:
Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual.
Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago.
For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate
bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to
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Subject
Medicine