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NR 509 SOAP Note- Week 2 Shadow Health
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NR 509 SOAP Note- Week 2 Shadow Health
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NR 509SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: T.J. Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170 89 kg 140/ 89 20 98.5 F 99% Medication: Penicillin-rash/hives
cm 81 Food: No known food allergies
Environment: Cat dander, Dust-sneezes, pruritus, wheezing, asthma
flare up
History of Present Illness (HPI)
Chief Complaint (CC) “I’ve been having breathing problems, and my inhaler just isn’t working the way CC is a BRIEF statement identifying
it normally does” why the patient is here - in the
Onset Began two days ago patient’s own words - for instance
Location Lungs "headache", NOT "bad headache for 3
days”. Sometimes a patient has more
Duration Lasts several minutes
than one complaint. For example: If
Characteristics Patient reports wheezing and chest tightness but no chest pain the patient presents with cough and
sore throat, identify which is the CC
Aggravating Factors Movement, lying flat on back, worse at night, cats and dust and which may be an associated
Relieving Factors Hot showers, proventil inhaler partially helps symptom
Treatment Proventil inhaler 90 mcg 2 puffs, has been using 3 puffs
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Proventil 90 mcg Every 4 hours PRN 25 years Asthma
Acetaminophen 500 mg Every 8 hours PRN (once Unknown Headache
a week or less)
Advil 600 mg (3 tablets) PRN TID Since her Menstrual cramps
menses started
Metformin Unknown Unknown (No longer 3 years ago Type 2 diabetes
taking)
Tramadol 50 mg Three times a day (No 3 months ago Foot pain
longer taking)
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Diagnosed with Type 2 Diabetes at the age of 24, non-compliant with diet and medications.
Immunizations up to date with the exception of the flu shot.
Diagnosed with asthma at the age of 2.5 and was last hospitalized at the age of 16.
Heavy menstrual bleeding with irregular cycles.
Denies surgical history, broken bones, or recent hospitilizations.
Was hospitalized for asthma when she was a little girl and has never been intubated for asthma exacerbation.
Menarche at age 11.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Single, unmarried, no children
Works 32 hours a week at Mid-American Copy & Ship as a supervisor
Going to school to obtain a bachelors degree in accounting
Enjoys reading on her e-book reader, going to church activities and watching TV
Denies tobacco use
Friends smoke when they go out a couple times a month
Used to use illicit drugs-marijuana, denies currently. Used marijuana “a lot” and “every weekend” for 5-6 years, from ages 15-21 and stopped
because it “wasn’t fun” Last usage was age 20-21
Social alcohol use (2 times per month)
Uses seatbelts consistently
Has working smoke detectors in her home/Lives with her mom and sister
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Mother-HTN, HLD/Father-Type 2 diabetes, HLD, HTN-Died 1 year ago at age 58 in a car accident
Brother-Obese, no other known health problems
Sister-Asthma-well controlled and is overall healthy
Maternal grandmother-Died at age 73 from a stroke 5 y ago-Hx: HTN, HLD Maternal grandfather-Died at age 80 from heart attack-Hx: HTN,HLD
Paternal grandmother-Possible HTN and HLD, PT unsure/Paternal grandfather-Died from colon cancer, unknown medical hx, died years ago
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive
symptom and provide additional details.
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