NR 509 Week 6 abdominal pain SOAP Note, Latest, complete solution

SOAP Note Template
S:Subjective
Information the patient or patient representative told you

Initials: E.P Age: 78 Gender:F

Height Weight BP HR RR Temp SPO2 Pain Allergies
157.48 54kgs 110/ 92 16 37.0 99% 6/10 Medication: Latex
70 Food: None
Environment: None
History of Present Illness (HPI)
Chief Complaint (CC) Belly Pain and” having difficulty going to bathroom” CC is a BRIEF statement identifying
Onset Pain in lower abdomen over the past 5 days ,increasingly worse over the last why the patient is here - in the patient’s
2-3 days. own words - for instance "headache",
Location Lower part of her belly NOT "bad headache for 3 days”.
Sometimes a patient has more than
Duration 5 days
one complaint. For example: If the
Characteristics Dull and Crampy patient presents with cough and sore
throat, identify which is the CC and
Aggravating Factors Eating and Movement which may be an associated symptom
Relieving Factors Rest
Treatment Rest drinking warm water denies stool softeners or laxatives
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Accupril 10mg Daily 24 years High blood pressure
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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 maybe needed.

, High blood pressure
C-section
Gallstones
Cholecystectomy
Colonoscopy

Social History (SocHx) - 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.

Does not smoke or use drugs
Minimal alcohol consumption

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.

Son- 48 and healthy
Daughter- 48 and healthy
Brother #1 – HTN, hypercholesterolemia ,prostate ca died at age 80
Brother #2—HTN, died at age 81
Mother- hypertension and DM type 2 died at age 88
Father-hypertension and hypercholesterolemia died at age 82



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
xFatigue low energy ☐Itching Click or tap ☐Diplopia Click or tap ☐Earache Click or tap here ☐Hoarseness Click or tap here
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here to enter text. ☐Rashes Click or tap ☐Eye Pain Click or tap ☐Tinnitus Click or tap here ☐Oral Ulcers Click or tap here
xFever/Chills Denies here to enter text. here to enter text. to enter text. to enter text.
xWeight Gain Denies ☐Nail Changes Click ☐Eye redness Click or ☐Epistaxis Click or tap ☐Sore Throat Click or tap here
xWeight Loss Denies or tap here to enter tap here to enter text. here to enter text. to enter text.
☐Trouble Sleeping Click or text. ☐Vision changes Click or ☐Vertigo Click or tap here ☐Congestion Click or tap here
tap here to enter text. xSkin Color Changes tap here to enter text. to enter text. to enter text.