CC: “Here for a follow-up after recent lab work.”
HPI: The patient is a 42-year-old male who returns for follow-up after his annual physical examination. He reports no
new symptoms since his last visit. He continues to take his medications as prescribed and has made some efforts to
improve h...
CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 08/17/24 Time: 1300
M.M.
Ethnicity: Black Age: 42 Sex: M
SUBJECTIVE (must complete this section)
CC: “Here for a follow-up after recent lab work.”
HPI: The patient is a 42-year-old male who returns for follow-up after his annual physical examination. He reports no
new symptoms since his last visit. He continues to take his medications as prescribed and has made some efforts to
improve his diet and physical activity, though he admits consistency has been challenging.
Previous Medical History: HTN, Hyperlipidemia
Medications: Lisinopril 10mg daily, Atorvastatin
Allergies: NKA
Medication Intolerances: None
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Alive- diabetes 2
F: MI at 50, deceased
Social History: The patient is a non-smoker, drinks alcohol occasionally, works as an IT professional, sedentary lifestyle,
married, and lives with his wife and two children .
REVIEW OF SYSTEMS (must complete this section)
General: Denies fatigue, night sweats and Cardiovascular: Denies, palpitations, chest
weakness pain,
shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Denies cough or shortness of
breath
Eyes: Denies and visual changes, eye Gastrointestinal: Denies abdominal pain,
drainage or eye pain nausea, or changes in bowel habits
Ears: Denies ear pain and swelling Genitourinary/Gynecological: Denies
increased urine output, dysuria. Denies foul
urine and
hematuria
Nose/Mouth/Throat: Denies nasal Musculoskeletal: Denies pain or muscle
congestions weakness
or sore throat
Breast: Deferred Neurological: Denies numbness, tingling
or
weakness in the legs
Heme/Lymph/Endo: Denies swollen Psychiatric: Denies symptoms of
glands, bruising, bleeding, and edema. depression,
anxiety, mood swings, hallucinations,
delusions, or behavioral disturbances.
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
, Weight: H eight: BMI: 29 BP: Temp: 36.6 Pulse: 72 Resp: 17
88.8kg 175cm 124/76
General Appearance: Appears alert, active, and appropriately dressed for age and surroundings.
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