MSN FNP SOAP NOTE
TYPHON CASE log #: Date: 4/3/25 Time: 09:30
Patient initials (fictitious): C.R Age: 66 Gender: Female
Chief Concern (CC): 4-week follow up on chronic conditions and recurrent sinus infections.
HPI: A standard follow up. 66 y.o female patient presents for routine follow up and yearly
physical. Patient continues with sinus pressure and congestion. She is also still having
diarrhea, and she was encouraged to follow up with her GI specialist. Will trial montelukast
for the recurrent congestion. Labs ordered. Patient reports her insurance is no longer covering
her eliquis or anoro, will send in again and advised pt to look into a good rx coupon. Patient
was advised to follow up with cardiology as well. Pt reports no other concerns at this time.
Denies chest pain, SOB, palpitations, fevers, chills, hematuria, or hematochezia.
Medications:
Fluticasone Propionate 50 MCG/ACT Suspension Shake and use 1 spray in each nostril daily
Gabapentin 800 mg tablet 1 tablet orally 4 times per day
Naproxen 500 mg tablet take 1 tablet by mouth twice daily with food or milk as needed every
12 hrs
Diltiazem HCL ER beads 120 mg capsule extended release 24 hrs take 1 capsule by mouth
daily
Atorvastatin Calcium 40 mg tablet take 1 tablet by mouth daily
Ventolin HFA 108 (90 base) MCG/ACT aerosol solution inhale 1 puff into the lunges every 4
hrs as needed
PMH:
Allergies:
● paxil - nausea and vomiting
● zoloft - dizziness
Chronic Illnesses:
, ● anxiety disorder
● asthma
● breast cancer
● COPD
● heart disease
● high cholesterol
● hypertension
● mental disease
● skin disease
● scoliosis
● sciatica
● Malignant melanoma of skin
Surgical History:
● breast cancer 2017
● cyst removal and ovary
● tubal ligation
● carpel tunnel
● deviated septum
Hospitalizations:
● Denies past hospitalizations
Family History:
● father - alive - congenital heart disease, anemia
TYPHON CASE log #: Date: 4/3/25 Time: 09:30
Patient initials (fictitious): C.R Age: 66 Gender: Female
Chief Concern (CC): 4-week follow up on chronic conditions and recurrent sinus infections.
HPI: A standard follow up. 66 y.o female patient presents for routine follow up and yearly
physical. Patient continues with sinus pressure and congestion. She is also still having
diarrhea, and she was encouraged to follow up with her GI specialist. Will trial montelukast
for the recurrent congestion. Labs ordered. Patient reports her insurance is no longer covering
her eliquis or anoro, will send in again and advised pt to look into a good rx coupon. Patient
was advised to follow up with cardiology as well. Pt reports no other concerns at this time.
Denies chest pain, SOB, palpitations, fevers, chills, hematuria, or hematochezia.
Medications:
Fluticasone Propionate 50 MCG/ACT Suspension Shake and use 1 spray in each nostril daily
Gabapentin 800 mg tablet 1 tablet orally 4 times per day
Naproxen 500 mg tablet take 1 tablet by mouth twice daily with food or milk as needed every
12 hrs
Diltiazem HCL ER beads 120 mg capsule extended release 24 hrs take 1 capsule by mouth
daily
Atorvastatin Calcium 40 mg tablet take 1 tablet by mouth daily
Ventolin HFA 108 (90 base) MCG/ACT aerosol solution inhale 1 puff into the lunges every 4
hrs as needed
PMH:
Allergies:
● paxil - nausea and vomiting
● zoloft - dizziness
Chronic Illnesses:
, ● anxiety disorder
● asthma
● breast cancer
● COPD
● heart disease
● high cholesterol
● hypertension
● mental disease
● skin disease
● scoliosis
● sciatica
● Malignant melanoma of skin
Surgical History:
● breast cancer 2017
● cyst removal and ovary
● tubal ligation
● carpel tunnel
● deviated septum
Hospitalizations:
● Denies past hospitalizations
Family History:
● father - alive - congenital heart disease, anemia
