Soap Note 1 “ADULT”  Wellness check up (10 points) Follow the  Soap Note: Use APA format and must include mia minimum of 2 Scholarly Citations. Must use the sample templates for your soap note. Keep this template for when you start clinicals. The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.

Title: Wellness Check-Up for an Adult Patient

Introduction
A wellness check-up is a routine evaluation conducted to ensure the overall well-being and health of an adult patient. This paper aims to provide a soap note for an adult wellness check-up, incorporating relevant patient history, chief complaint, history of present illness, assessment, and personalized treatment plan. The patient presented in this case is fictitious and specific to this assignment.

Patient Information
Name: John Doe
Age: 35
Gender: Male
Occupation: Office Manager

Patient History
John Doe is a 35-year-old male, an office manager by profession. He has no significant past medical history and has been generally healthy. His last routine check-up was two years ago, and he has not reported any significant health concerns since that time. He reports a sedentary lifestyle, spending most of his day sitting at a desk. He denies any tobacco, alcohol, or drug use. Family history includes cardiovascular disease in his paternal grandparents, but no history of diabetes, hypertension, or cancer. John Doe has medical insurance coverage, which includes preventive services.

Chief Complaint
John Doe presents for a routine wellness check-up and has no specific complaints or concerns at this time.

History of Present Illness
The patient reports no acute changes in his health status since his last visit. He denies any symptoms such as fatigue, weight loss, chest pain, shortness of breath, or gastrointestinal disturbances. There have been no recent significant life events or changes in stress levels. He denies any current medication or supplement use.

Assessment
John Doe’s vital signs are as follows:
– Blood Pressure: 120/80 mmHg
– Heart Rate: 70 bpm
– Respiratory Rate: 16 breaths per minute
– Temperature: 98.6°F
– Height: 6 feet
– Weight: 185 pounds
– Body Mass Index (BMI): 25

General physical examination reveals a well-developed, well-nourished male in no acute distress. Skin appears healthy and without any lesions, discoloration, or rashes. Head and neck examination is unremarkable, with no signs of lymphadenopathy or thyroid enlargement. Lung auscultation reveals clear breath sounds bilaterally. Heart auscultation demonstrates regular rate and rhythm with no murmurs, rubs, or gallops. Abdominal examination reveals no organomegaly or tenderness. Extremities exhibit normal range of motion and no edema. Neurological examination is grossly normal, with intact cranial nerves, motor strength, sensation, and coordination.

Based on the physical examination findings, John Doe appears to be in overall good health. However, considering his sedentary lifestyle, it is important to assess his risk factors for chronic diseases.

Plan
1. Screening Tests:
– Lipid Profile: To assess cardiovascular risk factors
– Fasting Blood Glucose: To evaluate for diabetes risk
– Complete Blood Count: To check for anemia or other hematological abnormalities
– Thyroid-Stimulating Hormone: To rule out thyroid dysfunction

2. Lifestyle Modifications:
– Encourage regular physical activity: Advise John Doe to engage in at least 150 minutes of moderate-intensity aerobic exercise per week.
– Promote a balanced diet: Recommend a diet rich in fruits, vegetables, whole grains, lean proteins, and low in saturated fats, sodium, and added sugars.
– Discuss smoking cessation: Advise John Doe to quit smoking if he has any history of tobacco use.
– Stress management techniques: Encourage stress-reducing activities such as mindfulness, deep breathing, or hobbies.

3. Immunizations:
– Annual influenza vaccine
– Tetanus, diphtheria, and pertussis booster every ten years
– Pneumococcal vaccine
– Hepatitis B vaccine (if not previously vaccinated)

4. Follow-up:
– Schedule a follow-up appointment in one year for routine check-up and to review any necessary screening test results.

Conclusion
The presented soap note highlights the essential components of a wellness check-up for an adult patient. Although John Doe has no specific complaints, it is crucial to evaluate his overall health, assess his risk factors for chronic diseases, and provide appropriate preventive measures. This approach helps to ensure the maintenance of optimal health and to identify and address potential health concerns in a timely manner.