Annual Wellness Check-Up SOAP Note for 37-Year-Old Hispanic Male (KV)

Subjective

CC: “I am here for my annual check-up for my work.”

HPI: HV, a 37-year-old Hispanic male, is visiting our clinic for his annual check-up as a requirement from his employer. He further describes his current state of health and states that he has no general health complaints. HV says that he has been exercising on a regular basis and eating healthy foods to reduce the dangers of developing diseases. He claims that at times, he experiences stress resulting from work pressures; nonetheless, he refutes that there has been a negative change in his general health conditions. He reports no diseases in the past two weeks or any significant alteration in his/her condition in the past month. In accordance with his history and physical examination, HV stated that he had been compliant with the medications for hypertension and hyperlipidemia. In this regard, he negates the occurrence of any side effects as a result of the current medications that are being used. In conclusion, HV seems to be satisfied with the health maintenance routine that he is implementing and is willing to do whatever else is necessary to meet these requirements for his job. He desires a guarantee that he is still fit to work in order to have further eligibility to work for his employer

Past Medical History

Medical problem list
Diagnosed with Hypertension in 2021
Diagnosed with Hyperlipidemia in 2022
Surgical: None reported
Recent hospitalizations/illness: None reported
Preventative care:

HV often goes for one annual wellness visit. He tracks his blood pressure and also adheres strictly to the required medical prescriptions. Getting into the lifestyleHV regularly engages himself in exercise as well as observing a balanced diet to maintain his optimum health condition. Among the tested factors that he cares much about is stress measures.

o Annual Wellness Visit: Vist was conducted on 15th September 2023.

o Blood Pressure Check: As per the record, she was last seen on 25-05-2024 which is quite normal.

o Lipid Profile Test: Taken on 11/12/2023 to find out if they are within the controlled level.

o Colorectal Cancer Screening: As planned, in line with the guidelines, the meeting is scheduled for 2025.

o Flu Vaccination: This is usually given every year, the last time being on 10/01/2023.

o Pneumococcal Vaccination: Taken at 35 years of age, the next dose is due in 5 years from 40 years of age.

o Dental Check-up: Likely dental visit – 03/10/2024; no abnormalities diagnosed yet.

Allergies
HV has no reported allergies to food, drugs, or environmental factors.
Medications
He currently takes Amlodipine 5mg once daily for his hypertension and Atorvastatin 20mg once daily for his hyperlipidemia.
Social History

– HV is married and works as a project manager for a construction company in his local area. He currently resides in a suburban city where he lives with his spouse and two children. HV maintains that he has been in a faithful union with his wife and exercising safe sex. He has a sedentary work profile, but he is also required to perform some strenuous activities based on his department’s requests or due to certain project-related pressures. Aside from work, HV likes playing football with his friends during weekends and takes an active part in his children’s schedules after school activities. He exercises regularly and has a healthy diet, mostly taking home-prepared meals but occasionally partaking in fast foods and red meat. He does not use tobacco or cigarettes and uses alcohol occasionally during events where he takes one or two glasses of alcohol. He also expresses that he has emotional support from his family and friends.

Family History

Both his parents are alive and free from any serious health complications or diseases that would have otherwise impeded their lives. His uncle passed away from colorectal cancer. His maternal grandfather had hypertension, while his paternal grandmother had type two diabetes, which also required medication and diet control. His father and mother are alive and healthy. There is no history of chronic diseases such as cardiovascular diseases, cystic fibrosis, or other forms of cancer. HV’s siblings are all healthy individuals, and none of them suffer from any kind of illness, such as diabetes or other genetic diseases. In summary, there are no substantial issues in HV’s family history that may predispose him to health problems affecting his current medical condition and management.

Review of Systems

 Constitutional: No weight loss, fever, fatigue or chills.

 Eyes: No visual changes, pain, or vision changes.

 Ears/Nose/Mouth/Throat: No ear pain, nose discharge, throat pain, or swallowing difficulties.

 Cardiovascular: Has an awareness of the heartbeat. No shortness of breath or chest pain.

 Pulmonary: No shortness of breath, wheezing, or coughing.

 Gastrointestinal: No nausea, abdominal pain, vomiting, or bowel movement changes.

 Genitourinary: No urinary incontinence, frequency, dysuria, urgency, hematuria, or hesitancy.

 Musculoskeletal: complains of lower back pain occasionally. No joint pain, swelling, or stiffness.

 Integumentary & Breast: No skin rashes, masses, or abnormal breast changes.

 Neurological: Has intermittent headaches. No convulsions, weakness, or numbness.

 Psychiatric: No anxiety, mood changes, or depression.

 Endocrine: No polyphagia, polydipsia, weight changes, or polyuria.

 Hematologic/Lymphatic: No lymph node swelling, easy bruising, or gum bleeding.

 Allergic/Immunologic: No itching, sneezing, or autoimmune diseases.

Objective

Height: 5’10” | Weight: 175 lbs. | BMI: 25.1

Labs, radiology, or other pertinent studies: Not Applicable

Physical Assessment

General Survey: HV is a middle-aged, healthy, physically fit Hispanic male with no signs of acute physical illness. He looks his stated age, maintains eye contact, is oriented, and is responsive.

Constitutional: Well nourished, of good nutritional status, no signs of respiratory distress.

Eyes: Pupils equal, round, and reactive to light. No conjunctival injection or discharge.

Ears/Nose/Mouth/Throat: Ears: Clear Tympanic membrane, no redness, wax, or discharge. Nose: Pink nose mucosa, no swelling or discharge. Mouth/Throat: Moist oral mucosa, no wounds or tonsillar hypertrophy.

Cardiovascular: Heart rate is regular. Regular rhythm. S1 and S2 heard. No gallops, murmurs, or rubs. Peripheral pulses are present and bilaterally symmetrical.

Pulmonary: Bilaterally clear chest on auscultation. Vesicular breath sounds are heard. No rhonchi, or wheeze.

Gastrointestinal: Abdomen flat, soft, no tenderness, no masses, splenomegaly or hepatomegaly. Normoactive bowel sounds are present.

Genitourinary: No perineal tenderness or renal angle tenderness.

Musculoskeletal: Normal range of motion in all Joints and extremities. No joint tenderness or swelling.

Integumentary & Breast: Skin is dry and warm, with no hyperpigmentation, rashes, or masses. No breast tenderness, swelling, or masses.

Neurological: Alert, oriented to time, place, and person. All the cranial nerves are intact. No focal neurological abnormalities.

Psychiatric: Appropriate affect and mood. Insight and judgment are intact.

Endocrine: No thyroid tenderness or swelling. No hypothyroidism or hyperthyroidism signs.

Hematologic/Lymphatic: No bleeding, bruising, or anemia. No lymphadenopathy.

Allergic/Immunologic: No allergic reactions, no angioedema or urticaria.

Risk Diagnoses

Risk for Cardiovascular Disease (CVD)

HV is currently more prone to CVD since hypertension and hyperlipidemia are regarded as being highly risky to one’s health. Hypertension is indicated by high arterial pressure, which causes damage to the vessels while leaving them narrowed; this might lead to heart disease and even stroke (Atar et al., 2021). The condition of hyperlipidemia – high cholesterol and triglyceride levels – can contribute to the progression of atherosclerosis in vessels and as a result of the evangelization of myocardial infarction and other CVAs (Handhle & Park, 2021).

Further, lifestyle factors that HV practices are occasional job stress that also causes some blood pressure and heart diseases to occur. This makes his alcohol consumption, however rare and in moderation it may be, a point of concern as far as cardiovascular health goes. The most important thing is that these risk factors need to be closely watched and controlled to avoid the occurrence of other severe forms of cardiovascular diseases and HV’s further health.

Risk of Diabetes Mellitus

Family history is a significant factor that puts HV at an increased risk of developing diabetes mellitus, particularly type 2 because the father’s grandmother has it. Hereditary factors are another important factor that suggests that the immune system of the patient may be affected by genes that are inherited from one’s parents. Moreover, HV was suffering from hyperlipidemia previously, which contributes to insulin resistance, a precursor of type 2 DM. Despite the lack of symptoms, including increased thirst, hunger, or unexplained weight changes, HV does not have such symptoms, but such indicators do not exclude the risk. He smokes, drinks alcohol occasionally, has other metabolic risks such as hyperlipidemia, and his age puts him at risk of developing diabetes. Screening should be done frequently, along with lifestyle changes, in order to diagnose the disease at an early stage or to avoid the occurrence of the condition.

3. Risk of Renal Disease

HV is at high risk of renal disease, given his history of hypertension and hyperlipidemia. High blood pressure weakens and damages the small blood vessels in the kidneys gradually through a process referred to as glomerulosclerosis, which makes the kidneys less capable of filtering blood wastes and fluids. This may cause chronic kidney disease (CKD) or worsening of the preexisting kidney disease (Tian & Liang, 2021). Hyperlipidemia causes atherosclerosis that leads to stenoses of renal arteries and subsequently decreased renal perfusion. Restricted blood flow also contributes to the intensification of CKD and the deterioration of the kidney’s ability to filter waste. Also, high GH and lipid levels are associated with high blood pressure, which can worsen kidney disease; therefore, renal function should be closely checked. Since many renal diseases are asymptomatic in the early stages, it is possible for major damage to occur before symptoms arise; hence, it is important to regularly evaluate and manage these risk factors (Tian & Liang, 2021). As part of HV’s health assessment, his renal function should be periodically checked to ensure that there is no development of renal dysfunction that would warrant a change in the care plan.

Risk of Colorectal Cancer

HV’s old age and a family history of the disease puts him at high risk of getting the disease. Colorectal cancer cases increase as one reaches 45 years of age or older; thus, it is crucial to undertake the appropriate screening process. Even though HV has no self-history of cancer, the family history with an emphasis on first-degree relatives suffering from colorectal cancer poses additional risks to him. Food choices and alcohol also influence the development of the disease, and diets that are rich in red and processed meats increase the risk of colorectal cancer in contrast to diets that include high fiber, fruits, and vegetables reduce the risk of colorectal cancer (Ladabaum et al., 2020).

Adherence to recommended screening guidelines should also be included in HV’s approach to health maintenance since early detection of precancerous polyps or early-stage cancer has superior outcomes. Due to the importance of early detection of the disease and the fact that many colorectal cancer cases are preventable either by screenings or a change in lifestyle, it is important for HV to monitor his colorectal health to reduce this risk (Ladabaum et al., 2020).

Assessment/Plan

Problem Lists

Leading diagnosis: Check up or examination of an Adult Patient for any General Medical Complaint With Some Irregularity | ICD-10 CODE Z00. 01

HV is here today for his annual fitness check-up, which is mandatory in his line of work. This type of visit covers screening and monitoring for the presence of disease, controlling existing conditions, and maintaining Health.

Hypertension | ICD-10 CODE I10

HV likewise had a history of hypertension, which is one of the common risk factors that tend to cause cardiovascular as well as renal illnesses. This is to ensure he does not face issues like heart disease and stroke as a result of his blood pressure (Jones et al., 2020).

Hyperlipidemia: | ICD-10 CODE E78.5

Another challenge is higher cholesterol, which causes atherosclerosis, cardiovascular diseases, and other lipid profile complications in HV’s; hence, it requires constant monitoring and treatment. It is vital that his lipid panel is secured and checked frequently to monitor the progress of his condition (Handhle & Park, 2021).

Pre-existing Medical Condition: Risk Factors History Type 2 Diabetes Mellitus | ICD-10 CODE Z83. 3

Using the family history criterion, one can state that HV is at a higher risk of developing type 2 diabetes compared to the other conditions listed in the table. Screening and general safety measures should be in place to identify and contain this risk sooner (Ortiz-Martínez et al., 2022).

Risk of Renal Disease | ICD-10 CODE Z13.6

Based on HV’s medical history of hypertension and hyperlipidemia, it is expected that HV has the potential to develop a chronic kidney disease. Since kidney function should be constantly checked to prevent any damage, tests are carried out to ensure early detection and correct management (Tian & Liang, 2021).

Family History Colorectal Cancer: ICD-10 CODE Z12. 11

HV has a family history of type 2 diabetes, and this raises the possibility of him being affected by it. However, as HV enters the age range most affected by colorectal cancer, general preventive practices that include colonoscopy to check for precancerous conditions are encouraged (Ladabaum et al., 2020).

Risk Factors: Occupational Exposure | ICD-10 code: Z57. 9

This shows that HV is exposed to stress at the workplace and different occupational risks that may have adverse health consequences on his health; therefore, periodic check-ups and counseling should be provided to fit the situation (Perry et al., 2021).

Immunisation – ICD 10 Code Z23

Monitoring HV’s vaccination record is invaluable in passing on immunizable illness prevention to the next generation. This means it is crucial to track his immunization status often (Perry et al., 2021).

Diagnostics

Laboratory Tests:

Complete Blood Count (CBC): This test is used to determine the presence of anemia, infections, or other hematologic problems (Perry et al., 2021).
2. Comprehensive Metabolic Panel (CMP): This panel assesses general metabolic health and dysfunction, liver and kidney functions, and electrolyte status (Perry et al., 2021).
3. Lipid Panel: To review HV’s lipid profile and identify potential factors associated with cardiovascular disease, as HV has a history of hyperlipidemia (Handhle & Park, 2021).
4. Hemoglobin A1c: To check whether HV has diabetes or pre-diabetes, particularly considering the patient’s family history of type 2 diabetes (Ortiz-Martínez et al., 2022).
5. Thyroid Stimulating Hormone (TSH): For the assessment of thyroid functions, because HC has stress and other potential symptoms such as sporadic palpitations (Perry et al., 2021).
6. Electrocardiogram (EKG): To monitor the heart rate and rhythm and to check for any signs of arrhythmias or any instances of palpitations that the patient has experienced, albeit occasionally (Atar et al., 2021).
7. Urinalysis: It can be used to diagnose kidney function and look for an infection or any other issue with the urinary tract (Perry et al., 2021).
Imaging:
Chest X-ray: This is a routine checkup to check if HV has any respiratory disease complaints or for general screening since HV occasionally experiences palpitation (Perry et al., 2021).
Colonoscopy: A colonoscopy should be booked for screening of colorectal cancer as it is advised for people who have reached 45 years of age or even those with risk factors (Ladabaum et al., 2020).

Treatment:

Hypertension Management:

Patients should remain on antihypertensive medications that were previously prescribed, such as an ACE inhibitor or a diuretic, and keep within desired hypertension levels.
General updates on the doses of medications prescribed to a patient because of his high blood pressure and the amount of progress made in lowering the readings.
Suggest dietary alterations, including a change of diet plan to a healthier one, including the DASH diet, exercise regularly, and practicing stress reduction strategies.
Advise quitting smoking if appropriate, as tobacco increases the risk of hypertension (Mills et al., 2020).

Hyperlipidemia Management:

Use or maintain current lipid-lowering medication usage, for instance, statins, to manage hyperlipidemia and prevent further cardiovascular complications.
Closely oversee lipid profiles in patients with CAD and adapt the dosage of the administered agent to target the ideal lipid values.
Encourage the patient to avoid foods containing trans fats or high in saturated fats and cholesterol while increasing his/her intake of fruits, vegetables, and fiber.

Diabetes Screening:

Execute a Hemoglobin A1c test to diagnose diabetes or prediabetes resulting from family history and risk factors
Educate the patients about modifiable risk factors for diabetes, its signs, and some of the measures to prevent the disease, which are being overweight and physical inactivity respectively.
Educate about risks for the development of diabetes, as well as action plans as to the kind of diet, carbohydrate intake, and glycemic control measures.

Education:

1Hypertension and Hyperlipidemia Education:

Some aspects to explain to HC are risks from factors associated with hypertension and hyperlipidemia, the possibilities of complications, the importance of following medical advice, and the intake of drugs alongside adopting lifestyle modification habits (Mills et al., 2020).
Explain the importance of follow-up blood pressure and lipid profile checks to enable assessment of the effectiveness of the treatments and redesign the regimen appropriately (Handhle & Park, 2021).

Diabetes Prevention Education:

Review with HV issues that increase the risk of diabetes, such as genetic predisposition, obesity, and lack of physical activity.
Provide recommendations for the appropriate lifestyle changes that include taking balanced diets, doing exercises and exercising regularly, and doing exercises to avoid the development of diabetes (Ortiz-Martínez et al., 2022).

Medication Adherence:

Apprise HV on aspects concerning the use of prescribed drugs, level of usage, possible by-effects, and function in illness control (Perry et al., 2021).

Lifestyle Modification:

Provide patients with individual guidelines for changing their mode of living including the consumption of healthy foods and portions, exercising, quitting smoking, and using stress relieving methods (Perry et al., 2021).

Follow-Up:
1. Medical Follow-Up:

Follow-up appointments should be set in 3 months for the next checkup regarding blood pressure, lipid profile, and diabetes status.
Peruse laboratory tests to evaluate the effectiveness of the treatment options and modify the medications if necessary, as well as respond to potential side effects and other complications (Perry et al., 2021).

Health Maintenance:

Continued encouragement for patients to keep with their management plans and changes they were instructed to make.
Provide information about programs and counseling services that include, but are not limited to, nutritionists, diabetes education classes, smoking cessation resources, physical therapy, and other forms of support groups that may offer guidance on lifestyle modifications, changes in diets, exercise regimes, and stress reduction strategies as stated by Jones et al. (2020).

References

Atar, D., Jukema, J. W., Molemans, B., Taub, P. R., Goto, S., Mach, F., … & Bonaca, M. P. (2021). New cardiovascular prevention guidelines: How to optimally manage dyslipidemia and cardiovascular risk in 2021 in patients needing secondary prevention?. Atherosclerosis, 319, 51-61. https://doi.org/10.1016/j.atherosclerosis.2020.12.013

Handhle, A., & Park, A. (2021). Hyperlipidaemia. Medicine, 49(9), 587-591. https://doi.org/10.1016/j.mpmed.2021.06.013

Jones, N. R., McCormack, T., Constanti, M., & McManus, R. J. (2020). Diagnosis and management of hypertension in adults: NICE guideline update 2019. British Journal of General Practice, 70(691), 90-91. https://doi.org/10.3399/bjgp20X708053

Ladabaum, U., Dominitz, J. A., Kahi, C., & Schoen, R. E. (2020). Strategies for colorectal cancer screening. Gastroenterology, 158(2), 418-432. https://doi.org/10.1053/j.gastro.2019.06.043

Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223-237. https://doi.org/10.1038/s41581-019-0244-2

Ortiz-Martínez, M., González-González, M., Martagón, A. J., Hlavinka, V., Willson, R. C., & Rito-Palomares, M. (2022). Recent developments in biomarkers for diagnosis and screening of type 2 diabetes mellitus. Current diabetes reports 22(3), 95-115. https://doi.org/10.1007/s11892-022-01453-4

Perry, A. G., Potter, P. A., Ostendorf, W. R., & Laplante, N. (2021). Clinical Nursing Skills and Techniques-E-Book: Clinical Nursing Skills and Techniques-E-Book. Elsevier Health Sciences.

Tian, Z., & Liang, M. (2021). Renal metabolism and hypertension. Nature communications, 12(1), 963. https://doi.org/10.1038/s41467-021-21301-5

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Question

1.) Create a PRETEND SOAP NOTE for ANNUAL CHECK-UP WELLNESS VISIT for a 37-year-old adult Hispanic patient who came into the clinic alone. Initials: KV. needs an annual wellness checkup for his work requirements

Annual Wellness Check-Up SOAP Note for 37-Year-Old Hispanic Male (KV)

2.) I attached a sample of SOAP NOTE
3.) This is a WELLNESS SOAP NOTE, you can use our SOAP NOTE TEMPLATE
4.) On the Assessment part put the rationale for why it is your main diagnosis and also rationales for the two differentials on why it is not the main diagnosis.
5.) Please make sure to put in-text citations on assessments, treatments, diagnostics, etc. that need references.
6.) Please use Clinical Guidelines references within the last 5 years,
7.) Make sure correct spelling, grammar, and abbreviation rules are correct too.
8.) PLEASE MAKE SURE IT’S PLAGIARISM FREE.

Annual Wellness Check-Up SOAP Note for 37-Year-Old Hispanic Male (KV)