Reference no: EM133697537

Question

Use the following encounter summary to complete the SOAP note. Patient visited the clinic today for an athlete physical and pre-assessment. The patient states that they are feeling well and do not have any concerns. Pain level is a 0/10. Patient denies the use of recreational drugs, tobacco, and alcohol. Patient reports to eat three meals per day and snacks between meals. Most meals are eaten at home and include meat, vegetables, and other carbohydrate sources. Patient drinks primarily water and sometimes Gatorade. Patient reports having a supportive and healthy family. Maternal grandfather has had a heart attack but is still living at 78 years of age. Patient states that there are no other known family illnesses. Patient reports between 7 and 10 hours of sleep per night. Participates in rigorous sports or training 6 days per week. Patient reports average grades in school. Immunizations are current. Complete blood panel results are all within normal ranges. Urinalysis is negative for performance enhancing and recreational drugs. Physical and chemical urinalysis all within normal ranges. Auscultation of heart and lungs are unremarkable. Percussion of abdominal region is unremarkable. Snellen eye exam 20/10. Deep tendon reflexes: bicep L2, R2, brachioradialis L2, R2, triceps.