Initials: EP
Age: 78
Gender: Female
Height: 5’2”
Weight: 120 lbs
BP: 110/70
HR:92
Temp: 37.0 C
SPO2: 99
RR: 16
Pain (1-10):
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Allergies:
Medication: NKDA
Food: none
Environment: Latex—“itchy rash”
History of Present Illness (HPI)
Chief Complaint (CC): “pain in my belly” and difficulty going to the bathroom
Onset: Constipation 5 days ago with the exception of an episode of was watery diarrhea 3 days ago
Location: “low in abdomen”
Duration: constant x 5 days
Characteristics: dull “crampy” feeling
Aggravating Factors: eating causes bloating and increased pain, physical activity
Relieving Factors: resting helps a little
Treatment: sips of warm water which did not work
NR 509 Week 5 Soap Note
SOAP NOTES TEMPLATE
States feeling like she needs to “rest more often” due to the pain.
Current Medications
Medication Dosage Frequency Length of Time
Used
Reason for Use
Accupril 10mg Daily Unknown hypertension
Past Medical History (PMHx)-
Mrs. Park is a pleasant 78-year-old Korean female. She has a history of hypertension and a
surgical history that is significant for cholecystectomy and one cesarean section. She is gravida three para
three with two living children and one still birth by cesarean section. Her only hospitalizations were for
her cholecystectomy, cesarean section and for the births of her other two children. She is unsure of date
of last tetanus, immunizations up to date, has not had flu shot this year. Her last colonoscopy was 10
years ago, and the results were normal. She denies a history of constipation. She does not take vitamins
or herbal supplements. She denies taking any pain medication. She does not check her blood pressure at
home.
Social History (SocHx)-
Mrs. Park was married for fifty years, her husband, Shin died 6 years ago. She is now seeing a
“gentleman friend” and is sexually active. She denies the use of contraceptives and state she has never
had a sexually transmitted disease. She denies vaginal or anal intercourse but reports that they “touch
and have oral sex”. She denies illicit drug use of any kind. She has never smoked and drinks one glass of
dry white wine on Sundays only. She stays active with water aerobics, Pilates, walking with friends, and
gardening. She lives with her daughter’s family and usually helps with household chores.
Family History (FamHx)-
Mother: deceased at age 88, cause of death CVA with known history of HTN, DM II
Father: deceased at age 82, passed away in his sleep with known history of HTN, hypercholesterolemia,
obesity
Maternal grandmother: history of DM II
Maternal grandfather: Died from heart attack with known history of coronary artery disease
Paternal grandmother: HTN, died from cancer
Paternal grandfather: died in his sleep without any known medical history
Siblings:
SOAP NOTES TEMPLATE
Brother, 80: HTN, hypercholesterolemia, slow growing prostate CA
Brother, 81: HTN
Son: Healthy age 48
Daughter: Healthy age 46
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
Check if
Positive
Symptom Details
x Fatigue States feeling like she needs to rest more
frequently but denies fatigue
Weakness
Fever/Chills
Weight Gain
Trouble Sleeping
Night Sweats
Other
Skin: Denies all symptoms
Check if
Positive
Symptom Details
Itching
Rashes
Nail
Skin Color
Other
HEENT: Denies all symptoms
Check if
Positive
Symptom Details
Diplopia
Eye Pain
Eye redness
Vision changes
Photophobia
Eye discharge
Eye discharge
Earache
SOAP NOTES TEMPLATE
Tinnitus
Vertigo
Hearing Changes
Hoarseness
Sore Throat
Congestion
Rhinorrhea
Other
Respiratory: Denies all symptoms
Check if
Positive
Symptom Details
Cough
Hemoptysis
Dyspnea
Orthopnea
Pain on Inspiration
Other
Neuro: Denies all symptoms
Check if
Positive
Symptom Details
Syncope or Lightheadedness
Headache
Numbness
Tingling
Sensation Changes RUE
LUE
RLE
LLE
Speech Deficits
Other
Cardiovascular: Denies all symptoms
Check if
Positive
Symptom Details
Chest pain
SOB
Exercise Intolerance
Orthopnea [Show Less]