CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name:Edgar Harvey Course: Physical assessment
Patient Name: (Initials ONLY) A.D Date: Time: 1400 hours
Ethnicity: White Age: 54 Sex: Female
SUBJECTIVE (must complete this section)
CC: Dizziness, “the room is spinning.”
HPI: C/o dizziness that he feels in his head, since last week following a cold. Sx onset was sudden and are
continuous, beginning daily after waking up. Denies loss of coordination or pain but feels like “both the room
and I are spinning,” dizziness rated 8/10. Sx worsen when pt moves his head. Pt has attempted to take
loratadine and Sudafed without relief. Sx associated with N/V and inability to go to work since onset.
Medications: Claritin, Sudafed (PRN for sx)
Previous Medical History:
Allergies: +seasonal allergies
Medication Intolerances: none
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: none
FAMILY HISTORY (must complete this section)
M: Dad: Died at 60 of MI, also had T2DM
Older Brother: HTN
Younger brother: T2DM
MGM:
MGF:
F:
PGM:
PGF:
Social History: Divorced and has custody of 2 teenage children whom he lives with
Exercise- plays basketball on Wednesdays with friends
OccupaQon- college professor
Diet- Pt reports he, “normally eats well,” but has not eaten much due to N/V over the past week. Tobacco- 1 pack/day
since his 20’s
Alcohol/drugs- Denies recreaQonal drugs, 3-4 beers on the weekend Sexual History: Denies
REVIEW OF SYSTEMS (must complete this section)
General: Reports anxiety, denies fever, chills, or weight Cardiovascular: Denies chest pain, edema, or
loss palpitations.
10122023 Page 1 of 3
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Student Name:Edgar Harvey Course: Physical assessment
Patient Name: (Initials ONLY) A.D Date: Time: 1400 hours
Ethnicity: White Age: 54 Sex: Female
SUBJECTIVE (must complete this section)
CC: Dizziness, “the room is spinning.”
HPI: C/o dizziness that he feels in his head, since last week following a cold. Sx onset was sudden and are
continuous, beginning daily after waking up. Denies loss of coordination or pain but feels like “both the room
and I are spinning,” dizziness rated 8/10. Sx worsen when pt moves his head. Pt has attempted to take
loratadine and Sudafed without relief. Sx associated with N/V and inability to go to work since onset.
Medications: Claritin, Sudafed (PRN for sx)
Previous Medical History:
Allergies: +seasonal allergies
Medication Intolerances: none
Chronic Illnesses/Major traumas: none
Hospitalizations/Surgeries: none
FAMILY HISTORY (must complete this section)
M: Dad: Died at 60 of MI, also had T2DM
Older Brother: HTN
Younger brother: T2DM
MGM:
MGF:
F:
PGM:
PGF:
Social History: Divorced and has custody of 2 teenage children whom he lives with
Exercise- plays basketball on Wednesdays with friends
OccupaQon- college professor
Diet- Pt reports he, “normally eats well,” but has not eaten much due to N/V over the past week. Tobacco- 1 pack/day
since his 20’s
Alcohol/drugs- Denies recreaQonal drugs, 3-4 beers on the weekend Sexual History: Denies
REVIEW OF SYSTEMS (must complete this section)
General: Reports anxiety, denies fever, chills, or weight Cardiovascular: Denies chest pain, edema, or
loss palpitations.
10122023 Page 1 of 3
This study source was downloaded by 100000892566046 from CourseHero.com on 11-02-2024 15:26:31 GMT -05:00
https://www.coursehero.com/file/239092525/Soap-note-week-7pdf/
