NURS 624_assignment 7.1_topic based soap note
S.O.A.P. Note Template
Case ID#: NURS 624_assignment 7.1
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
Female
55 years
Subjective History
Chief Complaint
Chief complaint of fatigue, increased thirst, increased appetite, and increased urination.
History of Present Illness
This is a pleasant 55 year old female who presents to the clinic with a chief complaint of
increased fatigue and overall “feeling run down.” She also endorses increased thirst
and the need to drink water all day, increased appetite and the need to snack
frequently. She also endorses having to wake up more frequently at night to urinate
frequently which she states is new. She states that the has been in her usual state of
health until she began to feel these symptoms over the last 2 months. She denies any
pain, dizziness, shortness of breath, chest pain, or vision changes. She states she
wakes up feeling more tired than usual and feels fatigued throughout the day. She does
state that her fatigue does interfere with her daily activities and when she can, she
attempts to take brief nap. She also states that she has felt less motivated to go on her
daily walks or her twice weekly swimming. She says that she’s always tried to drink
water all day, but feels this constant feeling of thirst and that she is constantly refilling
her water bottle. She states this is similar with food and that she continually feels
hungry and is snacking more in between her meals. She states she has recently gained
12 pounds over the last 3 months. She states that she is also urinating more frequently
throughout the day and at night. She states that she is urinating more than 7 times per
day. Per the patient, she rarely needed to wake up at night to urinate prior to two
, NURS 624_assignment 7.1_topic based soap note
months ago, but over the last two months, she wakes up 3-4 times per night to drink
water and urinate. She denies any burning, hematuria, or discharge and states she is
completely emptying her bladder. She denies any abdominal pain, nausea or vomiting.
She is not able to identify if anything makes her symptoms worse and the only relief she
has is from rest.
Past Medical History
The patient’s past medical history is positive for intermittent asthma well controlled with
Albuterol PRN as well as seasonal allergies that are will managed with OTC Zyrtec and
Flonase. Other history is hypertension (diagnosed 8 years ago) well controlled on
Lisinopril and hyperlipidemia that she is on atorvastatin for. She is a G2P2, denies any
miscarriages or abortions. Her las PAP smear was 3 years ago and was normal. Last
mammogram 1 month ago and was normal. She had a colonoscopy 5 years ago that
was normal and was told to get another colonoscopy in 10 years (due in 5 years) Past
surgical history is significant for appendectomy at age 12 and a cesarean at age 28.
She is up to date on all childhood vaccines but does not get the yearly flu vaccine.
ALLERGIES: Penicillins, has had Sulfa drugs with no complications
MEDICATIONS:
-Albuterol 90mcg/actuation, 1 inhalation PRN
-Zyrtec OTC
-Flonase OTC
-Lisinopril 20 mg daily
-Atorvastatin 20 mg daily
Family History
Mother: HTN, hyperlipidemia
Father: Obesity, DMII, HTN, hyperlipidemia, passed away at age 62 from CVA
Brother: DMII, obesity
Brother: HTN, asthma
Maternal Grandfather: Passed away from heart failure at age 70
Maternal Grandmother: Passed away from “natural causes” at age 72
Paternal Grandfather: Passed away from MVA at age 34
Paternal Grandmother: Passed away from pneumonia at age 80
Personal/Social History
The patient is a college graduate who currently works as a middle school teacher. She
is married to her husband of 34 years and lives at home with her husband and 2 dogs.
S.O.A.P. Note Template
Case ID#: NURS 624_assignment 7.1
Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
Basic Information
Female
55 years
Subjective History
Chief Complaint
Chief complaint of fatigue, increased thirst, increased appetite, and increased urination.
History of Present Illness
This is a pleasant 55 year old female who presents to the clinic with a chief complaint of
increased fatigue and overall “feeling run down.” She also endorses increased thirst
and the need to drink water all day, increased appetite and the need to snack
frequently. She also endorses having to wake up more frequently at night to urinate
frequently which she states is new. She states that the has been in her usual state of
health until she began to feel these symptoms over the last 2 months. She denies any
pain, dizziness, shortness of breath, chest pain, or vision changes. She states she
wakes up feeling more tired than usual and feels fatigued throughout the day. She does
state that her fatigue does interfere with her daily activities and when she can, she
attempts to take brief nap. She also states that she has felt less motivated to go on her
daily walks or her twice weekly swimming. She says that she’s always tried to drink
water all day, but feels this constant feeling of thirst and that she is constantly refilling
her water bottle. She states this is similar with food and that she continually feels
hungry and is snacking more in between her meals. She states she has recently gained
12 pounds over the last 3 months. She states that she is also urinating more frequently
throughout the day and at night. She states that she is urinating more than 7 times per
day. Per the patient, she rarely needed to wake up at night to urinate prior to two
, NURS 624_assignment 7.1_topic based soap note
months ago, but over the last two months, she wakes up 3-4 times per night to drink
water and urinate. She denies any burning, hematuria, or discharge and states she is
completely emptying her bladder. She denies any abdominal pain, nausea or vomiting.
She is not able to identify if anything makes her symptoms worse and the only relief she
has is from rest.
Past Medical History
The patient’s past medical history is positive for intermittent asthma well controlled with
Albuterol PRN as well as seasonal allergies that are will managed with OTC Zyrtec and
Flonase. Other history is hypertension (diagnosed 8 years ago) well controlled on
Lisinopril and hyperlipidemia that she is on atorvastatin for. She is a G2P2, denies any
miscarriages or abortions. Her las PAP smear was 3 years ago and was normal. Last
mammogram 1 month ago and was normal. She had a colonoscopy 5 years ago that
was normal and was told to get another colonoscopy in 10 years (due in 5 years) Past
surgical history is significant for appendectomy at age 12 and a cesarean at age 28.
She is up to date on all childhood vaccines but does not get the yearly flu vaccine.
ALLERGIES: Penicillins, has had Sulfa drugs with no complications
MEDICATIONS:
-Albuterol 90mcg/actuation, 1 inhalation PRN
-Zyrtec OTC
-Flonase OTC
-Lisinopril 20 mg daily
-Atorvastatin 20 mg daily
Family History
Mother: HTN, hyperlipidemia
Father: Obesity, DMII, HTN, hyperlipidemia, passed away at age 62 from CVA
Brother: DMII, obesity
Brother: HTN, asthma
Maternal Grandfather: Passed away from heart failure at age 70
Maternal Grandmother: Passed away from “natural causes” at age 72
Paternal Grandfather: Passed away from MVA at age 34
Paternal Grandmother: Passed away from pneumonia at age 80
Personal/Social History
The patient is a college graduate who currently works as a middle school teacher. She
is married to her husband of 34 years and lives at home with her husband and 2 dogs.
