Exam (elaborations)
South University NSG 6440 Week 8 SOAP NOTE 2021
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South University NSG 6440 Week 8 SOAP NOTE 2021
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WEEK 8 SOAP NOTE. JUNE 2021SOAP NOTE
Name: W.Q Date: 06/10/21 Time: 1500
Age: 60 Sex: Male
SUBJECTIVE
CC: “annual”
HPI:
W.Q. is a 60-year-old, male, white patient. He is present today for his annual visit. He
reports difficulty when starting urine, decreased force, hesitancy, and dribbling after
voiding. He is also having trouble stop urine once started, along with urinary retention
and voiding multiple times. He has noticed increased urine at night. This has been
occurring for the past three months. The patient has a significant history for type 2
diabetes, hyperlipidemia, restless leg syndrome, essential hypertension, GERD. Chronic
diseases are management with medication, patient is at goal for chronic illness. He denies
painful discharge, dysuria, or pain.
Colonoscopy completed 6/2/21 WNL
Medications
Metformin 500mg po BID daily
Simvastatin 20mg po daily
Requip 2mg po at bedtime.
PMH
Allergies: N.K.D.A., denies food allergies
Medication Intolerances: Denies
, WEEK 8 SOAP NOTE. JUNE 2021
Chronic Illnesses/Major traumas
Restless leg syndrome
Type 2 diabetes mellitus
Hyperlipidemia
Hospitalizations/Surgeries
Denies
Family History
Mother- deceased, hyperlipidemia
Father- deceased, hyperlipidemia
Social History
Occupation: Teacher
Social habits: Denies smoking or drinking
Marital Status/Living situation: Lives with wife, no children.
Children: none
Nutrition: Patient states he eats out 4 to 5 times a week, drinks 2 cans of soda per day,
along with sedentary lifestyle.
Sleep Patterns: Patient sleep 8 hours every night without difficulty.
ROS
General Cardiovascular
Patient appears clean, well-dressed, Denies chest pain, claudication, irregular
talkative. No signs and symptom of distress heartbeat, orthopnea, palpitations
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