s subjective information the patient or patient representative told you initials bf age 58 years old gender male height 5’11” weight 197lbs bp 14690
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NR 509
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NR 509 WEEK 4
SOAP NOTES
TEMPLATE
S: Subjective
Information the patient or patient representative told you.
Initials: BF
Age: 58 years old
Gender: Male
Height: 5’11”
Weight: 197lbs
BP: 146/90
HR: 104
Temp: 19
SPO2: 98%
Pain (1-10): 0/10
Allergies
Medication: Codeine—Nausea and vomiting
Food: No Known Food Allergies
Environment: No Known Environmental Allergies
History of Present Illness (HPI)
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 symptom
Chief Complaint (CC): Chest
Pain/Tightness Onset: 1 month
Location: Center of my chest”
Duration: “It lasts 2-3 minutes when it happens”
Characteristics: “Intermittent tightness and
discomfort” Aggravating Factors: Activity, yard work,
climbing stairs Relieving Factors: Rest
Treatment: No medication treatments, seeking medical treatment today
Current Medications
Medication Dosage Frequency Length of Time Reason for Use
Used
Metoprolol 100mg Daily 1 year Hypertension
Atorvastatin 20mg Daily at 1 year High cholesterol
bedtime
Omega 3 Fish 1200mg Twice Daily 1 year High cholesterol
Oil
, NR 509 WEEK 4
SOAP NOTES
TEMPLATE
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.
Mr. Foster had a Tdap in October 2014 and has received the influenza vaccine for this season. He
reports a codeine allergy which caused nausea and vomiting. He denies any history of major illness,
hospitalizations, or surgeries. He denied any history of diabetes, coronary artery disease, or peripheral
vascular disease. His only reported medical diagnoses are hypertension and high cholesterol. He also
reports an approximate weight gain of 20 pounds over the past two years.
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.
Mr. Foster is married and works full-time as an engineer at a civil engineering firm. He denies any
history of smoking tobacco or any illicit drugs, including marijuana, cocaine, or heroin. He avoids soda,
and reports that his only alcohol intake is 2-3 beers on the weekends “if I’m grilling”. He likes to ride
bicycles but reports his last one was stolen. He intends to purchase another bicycle soon so that he can
start riding again. Mr. Foster enjoys fishing, watching sports (including his sons body building
competitions), and doing repairs on small electronics.
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.
Mr. Foster denies any known family history of stroke, DVT or pulmonary embolism. He reports that his
father died of colon cancer at the age of 75 years and had a history of hypertension, hyperlipidemia,
obesity. Mr. Fosters mother is 80 years old and has hypertension and diabetes type II. He reports that
his brother died at the age of 24 years from a motor vehicle accident. His sister is 52 years old and has
hypertension and diabetes type II. Mr. Fosters maternal grandfather died of a heart attack at 54 years
of age, and his maternal grandmother died of breast cancer at 65 years of age. Mr. Fosters paternal
grandfather died of “old age” at 85 years of age, and his paternal grandmother died of pneumonia at 78
years of age. Mr. Foster has a healthy 26-year-old son and a 19-year-old daughter with asthma.
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
Constitutional
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Symptom Details
Positive
Fatigue
Weakness
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