NURS 5337 SOAP Notes 2 CP1 & CP2 |2026 Edition | Complete Solutions &
Explanations | University of Texas, Arlington
SOAP Note Template. SOAP Notes 1 and 2. CP1 & CP2
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
MR, 53 y/o, Male, patient is a reliable source
Mother and father:
HTN/HLD/DM2. No
siblings.
Personal/Social Hx:
Chief Complaint/RFE: Construction work x 19
Both feet are itching x 1 yr. years. Current smoker -
1 ppd. Denies drinking
Hx Present Illness: (write in paragraph format) or drug use.
MR 53 y/o male presents to clinic for bilateral foot itching are x 1 yr. Patient throws concrete on roads for a living x 19
years. States increased workload past couple of days. Patient was seen here 10/2022 for same complaint about feet, states the
same and was RX nyastatin topical cream and did not work.
CURRENT HEALTH
, Medications:
Albuterol sulfate 108 mcg/act inh aerosol solution 2 puff qid PRN SOB (Vallerand & Sanoski, 2022)
MOA: Binds to beta 2 adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and
increased levels of cAMP. Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and
decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways. Relaxation of airway
smooth muscle with subsequent bronchodilation. Relatively selective for beta 2 receptors.
SE: chest pain, palpitations, nervousness, restlessness, tremor, PARADOXICAL BRONCHOSPASM
Typical dose: 2 inhalations every 4-6 hr or 2 inhalations 15 minutes before exercise
Education: Instruct patient to take albuterol as directed. Do not double doses or increase the dose or frequency of
doses; may cause adverse effects, PARADOXICAL BRONCOSPASM (more likely with first dose from new canister),
or loss of effectiveness of medication
Fenofibrate 145 mg po qd (Vallerand & Sanoski, 2022)
MOA: Fenofibric acid primarily inhibits triglyceride synthesis
SE: DVT, DRUG REACTION EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-JOHNSON
SYNDROME, TOXIC EPIDERNAL NECROLYSIS, rash, fatigue/weakness, INTERSTITIAL LUNG DISEAS,
PULMONARY EMBOLISM, HYPERSENSITIVITY REACTIONS, HEPATOTOXICITY
Typical dose: 48- 145mg po qd
Education: Instruct patient to notify health care professional if S/S of liver injury (jaundice, abdominal pain, nausea,
malaise, dark urine, abnormal stool, pruritus), unexplained muscle pain, tenderness, or weakness occurs, especially if
accompanied by fever or malaise
Metformin 1000 mg po bid with meals (Vallerand & Sanoski, 2022)
MOA: Decreases hepatic glucose production. Decreases intestinal glucose absorption. Increases sensitivity to insulin
SE: abdominal bloating, diarrhea, nausea, vomiting, LACTIC ACIDOSIS
Typical dose: 500 – 1000 mg po bid
Education: Explain to patient the risk of lactic acidosis and the potential need for discontinuation of metformin therapy
if severe infection, dehydration, or severe or continuing diarrhea occurs or if medical tests or surgery is required. S/S
of lactic acidosis (chills, diarrhea, dizziness, low BP, muscle pain, abdominal pain, sleepiness, slow HR, dyspnea or
weakness) should be reported immediately
Ramipril 10mg po qd (Vallerand & Sanoski, 2022)
MOA ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also
prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin
levels and decrease aldosterone levels. Net result is systemic vasodilation
SE: cough, hypotension, ANGIOEDEMA
Typical dose: 2.5 - 20 mg po qd
Education: Instruct patient to notify health care professional immediately if rash; mouth sores; sore throat; fever;
swelling of hands or feet; irregular heartbeat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips or tongue;
or if difficulty swallowing or breathing occurs.
Simvastatin 5 mg po hs (Vallerand & Sanoski, 2022)
MOA: Inhibits HMG-CoA reductase, an enzyme which is responsible for catalyzing an early step in the synthesis of
cholesterol
SE: rash, abdominal cramps, constipation, diarrhea, flatus, heartburn, RHABDOMYOLYSIS, HYPERSENSITIVITY
REACTIONS
Typical: dose 5040 MG po qd hs
Education: Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness
occurs, especially if accompanied by fever or malaise.
Sitagliptin/januvia 100 mg po qd (Vallerand & Sanoski, 2022)
Explanations | University of Texas, Arlington
SOAP Note Template. SOAP Notes 1 and 2. CP1 & CP2
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
MR, 53 y/o, Male, patient is a reliable source
Mother and father:
HTN/HLD/DM2. No
siblings.
Personal/Social Hx:
Chief Complaint/RFE: Construction work x 19
Both feet are itching x 1 yr. years. Current smoker -
1 ppd. Denies drinking
Hx Present Illness: (write in paragraph format) or drug use.
MR 53 y/o male presents to clinic for bilateral foot itching are x 1 yr. Patient throws concrete on roads for a living x 19
years. States increased workload past couple of days. Patient was seen here 10/2022 for same complaint about feet, states the
same and was RX nyastatin topical cream and did not work.
CURRENT HEALTH
, Medications:
Albuterol sulfate 108 mcg/act inh aerosol solution 2 puff qid PRN SOB (Vallerand & Sanoski, 2022)
MOA: Binds to beta 2 adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and
increased levels of cAMP. Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and
decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways. Relaxation of airway
smooth muscle with subsequent bronchodilation. Relatively selective for beta 2 receptors.
SE: chest pain, palpitations, nervousness, restlessness, tremor, PARADOXICAL BRONCHOSPASM
Typical dose: 2 inhalations every 4-6 hr or 2 inhalations 15 minutes before exercise
Education: Instruct patient to take albuterol as directed. Do not double doses or increase the dose or frequency of
doses; may cause adverse effects, PARADOXICAL BRONCOSPASM (more likely with first dose from new canister),
or loss of effectiveness of medication
Fenofibrate 145 mg po qd (Vallerand & Sanoski, 2022)
MOA: Fenofibric acid primarily inhibits triglyceride synthesis
SE: DVT, DRUG REACTION EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-JOHNSON
SYNDROME, TOXIC EPIDERNAL NECROLYSIS, rash, fatigue/weakness, INTERSTITIAL LUNG DISEAS,
PULMONARY EMBOLISM, HYPERSENSITIVITY REACTIONS, HEPATOTOXICITY
Typical dose: 48- 145mg po qd
Education: Instruct patient to notify health care professional if S/S of liver injury (jaundice, abdominal pain, nausea,
malaise, dark urine, abnormal stool, pruritus), unexplained muscle pain, tenderness, or weakness occurs, especially if
accompanied by fever or malaise
Metformin 1000 mg po bid with meals (Vallerand & Sanoski, 2022)
MOA: Decreases hepatic glucose production. Decreases intestinal glucose absorption. Increases sensitivity to insulin
SE: abdominal bloating, diarrhea, nausea, vomiting, LACTIC ACIDOSIS
Typical dose: 500 – 1000 mg po bid
Education: Explain to patient the risk of lactic acidosis and the potential need for discontinuation of metformin therapy
if severe infection, dehydration, or severe or continuing diarrhea occurs or if medical tests or surgery is required. S/S
of lactic acidosis (chills, diarrhea, dizziness, low BP, muscle pain, abdominal pain, sleepiness, slow HR, dyspnea or
weakness) should be reported immediately
Ramipril 10mg po qd (Vallerand & Sanoski, 2022)
MOA ACE inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also
prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin
levels and decrease aldosterone levels. Net result is systemic vasodilation
SE: cough, hypotension, ANGIOEDEMA
Typical dose: 2.5 - 20 mg po qd
Education: Instruct patient to notify health care professional immediately if rash; mouth sores; sore throat; fever;
swelling of hands or feet; irregular heartbeat; chest pain; dry cough; hoarseness; swelling of face, eyes, lips or tongue;
or if difficulty swallowing or breathing occurs.
Simvastatin 5 mg po hs (Vallerand & Sanoski, 2022)
MOA: Inhibits HMG-CoA reductase, an enzyme which is responsible for catalyzing an early step in the synthesis of
cholesterol
SE: rash, abdominal cramps, constipation, diarrhea, flatus, heartburn, RHABDOMYOLYSIS, HYPERSENSITIVITY
REACTIONS
Typical: dose 5040 MG po qd hs
Education: Instruct patient to notify health care professional if unexplained muscle pain, tenderness, or weakness
occurs, especially if accompanied by fever or malaise.
Sitagliptin/januvia 100 mg po qd (Vallerand & Sanoski, 2022)
