Soap note <12 month

United States University

Student name

FNP 592: Common Illnesses Across the Lifespan

Instructor

Date

SOAP

SUBJECTIVE:

ID:

CC:

HISTORY OF PRESENT ILLNESS (HPI):

PAST MEDICAL HISTORY:

PAST MEDICAL PROCEDURES:

MEDICATIONS:

ALLERGIES:

FAMILY HISTORY:

Mom:

Dad:

Brother:

Sister:

Paternal grandpa:

Paternal grandma:

Maternal grandpa:

Maternal grandma:

SOCIAL HISTORY:

-SEXUAL/REPRODUCTIVE:

-TOBACCO USE/Vaping:

-ALCOHOL USE:

-DRUG USE:

-MARITAL HISTORY:

-OCCUPATION:

-EXERCISE/DIET:

-SLEEP/STRESS:

-HOUSING:

-SAFETY:

IMMUNIZATIONS:

SPIRITUAL:

SUICIDE/DEPRESSION:

ROS:

CONSTITUTIONAL:

INTEGUMENTARY:

HEAD, EYES, EARS, NOSE, THROAT:

RESPIRATORY:

NECK:

CARDIOVASCULAR:

GASTROINTESTINAL:

PERIPHERAL VASCULAR:

GENITOURINARY:

MUSCULOSKELETAL:

PSYCH:

NEURO:

HEMATOLOGIC:

ENDOCRINE:

ALLERGY/IMMUNOLOGY:

OBJECTIVE:

VITAL SIGNS:

P: BP: RR: T: SpO2 RA: Pain:

Ht: Wt: BMI:

PHYSICAL EXAM:

GENERAL survey:

HEENT:

NECK:

CHEST/BREAST:

RESPIRATORY:

CARDIOVASCULAR:

ABDOMEN/GI:

GASTROURINARY:

LYMPHATIC:

MUSCULOSKELETAL:

NEUROLOGIC:

PSYCHIATRIC:

SKIN:

PERIPHERAL VASCULAR:

ASSESSMENT:

1.

2.

3.

Final diagnosis:

PLAN:

Diagnostic labs:

Treatment/Therapeutic Plan (meds):

Education & F/U plan:

Referrals:

References

1.

2.

3

SOAP Note

United States University

FNP 592: Common Illnesses Across the Lifespan

Teacher

Student

July 13th, 2022

SOAP Note Week Two

ID: Ms. Castaneda (MD) is a pleasant, 58-year-old, Hispanic female in no acute distress presents to the clinic. MD appears to be a reliable historian and reports she drove herself to the clinic.

CC:

HISTORY OF PRESENT ILLNESS (HPI): denies current complaints and any changes to her health. Denies recent illness, fever, SOB, dizziness, and headache.

PAST MEDICAL HISTORY:

PAST MEDICAL PROCEDURES:

MEDICATIONS:

ALLERGIES:

FAMILY HISTORY:

Mom: Deceased at age 73 with MI. Hx of HTN

Dad: Deceased at 77 from stroke. Hx of HTN.

Paternal grandpa: Unknown

Paternal grandma: Unknown

Maternal grandpa: Deceased at 76 from unknown causes. No health problems.

Maternal grandma: Deceased at 76 from car accident. Hx of HTN.

SOCIAL HISTORY:

-SEXUAL/REPRODUCTIVE: Heterosexual. Has 4 living children. Denies birth control and being sexually active.

-TOBACCO USE/Vaping: Never a smoker

-ALCOHOL USE: One drink per week with friends

-DRUG USE: Denies use or experimentation.

-MARITAL HISTORY: Single

-OCCUPATION: Waitress at local restaurant

-EXERCISE/DIET: Reports eating predominantly Mexican food for all three meals a day. Reports walking around the block every evening for exercise.

-SLEEP/STRESS: Denies stress pertaining to home conditions, finances, and safety. Reports sleeping 6-7 hours of uninterrupted sleep per night.

-HOUSING: Lives with oldest daughter, Maria, in a nonsmoking single-family home with no pets and 3 grandchildren.

-HOBBIES:

-SAFETY: Reports using seatbelt while driving. Denies texting-and-driving, having guns in the home, and participating in risky behavior.

IMMUNIZATIONS: UTD on childhood immunizations. Received J&J COVID vaccine 3/23/2021, and Pfizer booster 2/1/22. Last flu 2/1/22, and Tdap on 2/28/19.

SPIRITUAL: Catholic, attends St. Mary’s Catholic Church

SUICIDE/DEPRESSION: Denies depression, SI/SA, and anxiety. Reports satisfaction with life.

ROS:

CONSTITUTIONAL: Denies changes in weight, increased fatigue, and diaphoresis.

EENT/MOUTH: Denies sinus pressure or pain. Denies eye itching, discharge, and photophobia. Reports last eye exam was 1/1/22 with no abnormal findings. Denies ear discharge, ear pain, and trouble hearing. Last hearing exam was 1/1/22 with normal results. Denies nosebleeds and rhinorrhea. Denies trouble swallowing or throat pain