NR509_SOAP_Note_"Brian Foster" SHADOW HEALTH 2020

SOAP Note Template
Initials: BF Age: 58 Gender: Male
HeightWeightBPHRRRTempSPO2Pain Allergies 5’ 1197kg146/
901041936.7C98 % Medication: Codeine (reports nausea, vomiting)
Food: none
Environment: none History of Present Illness (HPI)
Chief Complaint (CC) “Troubling chest pain” CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3
days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptomOnset A month ago
Location Midsternal
Duration Intermittent only lasts a few minutes
Characteristics Tightness and discomfort, denies current symptoms
Aggravating FactorsActivity e.g yard work or taking stairs
Relieving Factors Rest
Treatment None tried
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication (Rx, OTC, or Homeopathic)Dosage FrequencyLength of Time
UsedReason for Use
Metoprolol 100 mg PO Daily One year Hypertension
Artovastatin 20 mg Po @ HS One year Hyperlipidermia
Omega 3 Fish oil 1200 mg PO BID Click or tap here
to enter text.OTC supplement
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to enter text.Click or tap here to enter text.
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to enter text.Click or tap here to enter text.
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.S: Subjective
Information the patient or patient representative told you Hypertension diagnosed a year ago
Hyperlipidermia diagnosed a year ago
Vaccines: Tdap 10/2014 Influenza vaccine current
Surgical history: none
Hospitalizations: none
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.
Married lives with wife and has two children, denies stress at home, denies tobacco, marijuana & illicit drug use,alcohol:- 1-2 beers a week, enjoys gardening, and riding his bike- currently unable to ride it as it was stolen. Occupation: Engineer
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.
Father: HTN, Hyperlipidermia, Obesity, deceased from Colon Cancer
Mother: Age 60, DM2, HTN
Brother: deceased @ 24 MVA
Sister: 52 years old, HTN, DM2
Maternal Grandfather: Deceased due to MI @ 54
Maternal Grandmother:Deceased due to Breast Cancer @ 65
Paternal Grandfather: Deceased due “to old age” @ 85
Paternal Grandmother: Decesed PNA @ 78
Son: age 26 healthy
Daughter: age 19 Asthma
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.
Constitutional Skin HEENT
☐Fatigue Click or tap here to enter text.
☐Weakness Click or tap here to enter text.
☐Fever/Chills Click or tap ☐Itching Click or tap here to enter text.
☐Rashes Click or tap here to enter text.
☐Nail Changes Click ☐Diplopia Click or tap here to enter text.
☐Eye Pain Click or tap here to enter text.
☐Eye redness Click or ☐Earache Click or tap here
to enter text.
☐Tinnitus Click or tap here to enter text.
☐Epistaxis Click or tap ☐Hoarseness Click or tap here
to enter text.
☐Oral Ulcers Click or tap here to enter text.
☐Sore Throat Click or tap here