Posted: July 30th, 2023

Soap Note # __ Main Diagnosis: Z00.01-Annual Wellness Check-up

Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis: Z00.01-Annual Wellness Check-up
PATIENT INFORMATION
Name: S.N.
Age: 55 yrs
Gender at Birth: Male
Gender Identity: Male
Source: Patient
Allergies: No known food, environmental, or drug allergies.
Current Medications: Not currently taking any medications or herbal supplements.
PMH: No history of hospitalizations or chronic illnesses, such as cancer, hypertension (HTN), psychiatric diseases, asthma, or diabetes.
Immunizations: Received COVID-19 vaccine on 10/12/2021, influenza vaccine in 5/2021, and Tdap booster in 2010. Childhood immunizations are up-to-date but exact dates are not recalled.
Preventive Care: RBS done on 20/3/2021. B.P. measurements taken on 20/3/2021.
Surgical History: No history of recent or previous surgeries.

Family History: Raised by biological parents. His mother is 78 years old and has HTN and diabetes. His father is 85 years old with no chronic illness. His maternal grandfather died at 80 years old and had a history of BPH and HTN.
Social History: He is a small-scale farmer, married to one wife, and has three children. He neither smokes nor drinks.
Sexual Orientation: He is heterosexual and married to one wife.
Nutrition History: He follows a balanced diet, avoids fat-rich diets and processed foods, consumes fruits every day in the morning, and drinks seven glasses of water daily. He does not consume sweetened drinks or coffee.

Subjective Data:
Chief Complaint: “I am feeling great, but I am here for my annual check-up.”
Symptom Analysis/HPI: The patient’s last annual check-up was in May 2021, and no abnormal laboratory or physical findings were reported. Previous eye examination was in October 2021, dental review in November 2021, colonoscopy, and PSA test in January 2018. Blood Pressure and Blood Sugar screenings were done in March 2021, and Lipid profile tests were done in January 2017. The patient has no current concerns or complaints.

Review of Systems (ROS):
CONSTITUTIONAL: No fatigue, chills, general body weakness, night sweats, or fever.
RESPIRATORY: No dyspnea, wheezing, chest pains, or cough.
GASTROINTESTINAL: No nausea, abdominal pain, vomiting, or diarrhea.
NEUROLOGIC: No numbness, loss of consciousness, tingling, or confusion.
HEENT: H: No dizziness, headache, or confusion. Eyes: No itching, pain, diplopia, or blurry vision. Ears: No pain, hearing loss, tingling sensation, or discharges. Nose: No bleeding, itching, or discharge. Throat: No sore throat, edema, or voice changes.
CARDIOVASCULAR: No chest pains, palpitations, dizziness, or edema.
GENITOURINARY: No dysuria, discharge, urinary urgency, or hematuria.
MUSCULOSKELETAL: No muscle pains, joint swelling, joint pain, or muscle spasms.
SKIN: No hives, skin rashes, or hyperpigmentation.

Objective Data:
VITAL SIGNS: BP-110/90 mmHg, RR 19, Pulse rate 70b/min. SpO2 is 100%. Height-180cm, Weight-63kg, computed BMI-22.5.
GENERAL APPEARANCE: A white male, seated, alert, and well-nourished, with no signs of respiratory distress. There is no pallor, jaundice, cyanosis, dehydration, edema, or lymphadenopathy.
NEUROLOGICAL: Normal speech, A&O x3, typical gait, no tremors, normal speech, no cerebellar signs/symptoms, or motor-sensory loss.
RESPIRATORY: Chest wall is symmetrical, rises following respiration, no visible masses or scars, no tenderness, percussion note is tympanic, bilateral entry of air, breath sounds were normal following auscultation.
CARDIOVASCULAR: Normoactive precordium, palpable apical pulse mid-clavicular line at the 5th ICS, regular H.R., no thrills, no heaves. On auscultation, there were no murmurs, and S1 and S2 were heard.
GASTROINTESTINAL: Flat abdomen, umbilicus everted, moving with respiration, no masses, no tenderness or organomegaly; warm. Normoactive bowel sounds were heard.
INTEGUMENTARY: Dark, warm, and dry. No rashes, abrasions, lesions, or hives.
HEENT: H: Normocephalic, no scars, masses, or bruises. E: Pupils are equal, round, and reactive to light, with no discharges. E: No ear discharges or impacted wax. N: Symmetrical, patent nasal nares, no discharge or bleeding. Neck: No distended veins or lymphadenopathy and supple.
MUSCULOSKELETAL: No abnormalities, normal gait, normal reflexes, no deformities, and normal ROM.

ASSESSMENT:
55-year-old S.N. came to our clinical for his annual check-up. There are no current complaints. His last yearly check-up showed no abnormal findings. Past check-ups included eye exam, dental exam, Prostate screening, colonoscopy, lipid profile check-up, and B.P. and B.S. screenings. Family history includes HTN and diabetes in the mother and HTN and BPH in the maternal grandfather. General and physical examination revealed no abnormal findings.

Main Diagnosis:

ICD Z00.00 – Annual checkup with no abnormal findings.
Recommended Preventative Services and Screenings:

PSA screening – ICD 10-CM Z12.5: Recommended for screening for malignant cancers of the prostate. PSA screening is vital for men above 50 years, given the risk of developing prostate cancer.
Update for immunization – ICD-10-CM Z23: Recommend Tdap booster after ten years. The patient’s immunizations are up-to-date, except for Tdap.
Colonoscopy – ICD 10-CM Z12.11: Recommended for screening for malignant cancers of the colon. Important for individuals above 50 years to detect any rectal or colon abnormalities.
Blood Pressure screening – ICD 10-CM Z01.30: Recommended for regular assessment in adults above 50 years. The patient is at risk of developing hypertension due to the positive family history of HTN.
Blood Sugar Screening – ICD 10-CM R73.09: Recommended for assessing diabetes mellitus risk in individuals above 45 years. The patient is at risk due to the positive family history of diabetes.
Lipid profile Check – ICD 10-CM Z13.220: Recommended to assess lipid metabolism errors and cholesterol levels. CDC advises cholesterol check-ups every five years for adults above 20 years.
PLAN:
Investigations:

CBC: To investigate white blood cell differentials, RBC, and platelet levels.
Urinalysis: To assess for any abnormalities in the urine.
UECs: To assess electrolyte levels.
Lipid tests: To assess LDL, cholesterol, TGs, and HDL levels.
ECG and ECHO: To assess the electrical activity of the heart and any heart disorders.
Renal function tests: To assess kidney function.
TSH: For assessment of thyroid function.
Education:

Continue monitoring any health changes, and in case of any threatening health conditions, call 911.
Implement a physical exercise plan with at least four sessions per week.
Continue with a balanced diet, including more fruits and vegetables, and maintain the habit of drinking seven glasses of water daily.
Follow-ups:
Advise the patient to return to the hospital after one week to review the laboratory findings. He can schedule an appointment or make a call in case of any health issues. His next annual check-up is scheduled for January 2023.

References:

Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee*. (2018). Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Annals of internal medicine, 168(5), 351-358. https://doi.org/10.7326/M17-3203
Catalona, W. J. (2018). Prostate cancer screening. Medical Clinics, 102(2), 199-214. https://doi.org/10.1016/j.mcna.2017.11.001
Centers for Disease Control and Prevention. (2020). Diphtheria, tetanus, and pertussis vaccine recommendations. Retrieved January 31, 2021, from https://www.cdc.gov/vaccines/vpd/dtap-tdap-td/hcp/recommendations.html
Hibberd, P. L. (2020). Tetanus-diphtheria toxoid vaccination in adults. UpToDate. Retrieved February 1, 2021, from https://www.uptodate.com/contents/tetanus-diphtheria-toxoid-vaccination-in-adults
Saito, Y., Oka, S., Kawamura, T., Shimoda, R., Sekiguchi, M., Tamai, N., … & Inoue, H. (2021). Colonoscopy screening and surveillance guidelines. Digestive Endoscopy, 33(4), 486-519. https://doi.org/10.1111/den.13972
Vijan, S., & Elmore, J. G. (2020). Screening for lipid disorders in adults. UpToDate. Waltham, MA: UpToDate. https://www.medilib.ir/uptodate/show/4553

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