NURS 5337 SOAP Notes 1 and 2. CP1 & CP2 |2026 Edition | Complete Solutions & Explanations | University of Texas, Arlington
SOAP Notes 1 and 2. CP1 & CP2
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
J.F., 50 y/o, male, independent, patient is a reliable source.
Father and Mother:
DMII & HTN
Personal/Social Hx:
Chief Complaint/RFE: Denies ETOH, tobacco
Frozen shoulder x 10 months or drug use.
Hx Present Illness: (write in paragraph format)
OLD CART
50 y/o NEW male patient presents to clinic with LEFT shoulder pain x 10 months. Patient states he was diagnosed with DM frozen
shoulder in the past. Movement exacerbates the pain and states nothing alleviates pain, despite taking OTC NSAID and RX muscle
relaxers by another physician last year. Unable to lift over 10 lb with LUE. Denies trauma, numbness or tingling. Patient takes DM II
medications and frequently checks his glucose with an average of 126.
CURRENT HEALTH
Medications: Atorvastatin 40 mg PO HS, Trujardy 5-2.5-1000 ER 2 tablets PO AM with meals, Lispro 75/25 0.2 unit/kg SUBQ BID,
telmisartan 40 mg PO QD
Atorvastatin (Vallerand & Sanoski, 2022)
MOA: Inhibits HMG-CoA reductase, an enzyme which is responsible for catalyzing an early step in the synthesis of cholesterol.
S/E: rash, abdominal cramps, constipation, diarrhea, flatus, heartburn, RHABDOMYLOSIS
Typical dose (adult): 10-20mg once daily initially
Education: Instruct patient to notify health care provider if unexplained muscle pain, tenderness, or weakness, especially if accompanied
by fever or malaise, or signs and symptoms of liver injury (fatigue, anorexia, RUQ abdominal discomfort, dark urine, jaundice) occur.
Trujardy (WCG CenterWatch, n.d.)
MOA: Combo of empagliflozin, linagliptin and metformin. Empagliflozin is a SGLT2 inhibitor and reduces renal reabsorption of filtered
glucose and lowers renal threshold for glucose and thereby increases urinary glucose excretion. Linagliptin increases the concentrations of
active incretin hormones, stimulating the release of insulin in a glucose-dependent manner and decreasing the levels of glucagon in the
circulation. Metformin is an anti-glycemic agent that decreases hepatic glucose production, decreases intestinal absorption of glucose and
improves insulin sensitivity by increasing peripheral glucose uptake and utilization.
Typical dose (adult): Take Trijardy XR 10 mg/5 mg/1000 mg or Trijardy XR 25 mg/5 mg/1000 mg as a single tablet once daily. Take
Trijardy XR 5 mg/2.5 mg/1000 mg or Trijardy XR 12.5 mg/2.5 mg/1000 mg as two tablets together once daily.
S/E: URI, UTI, gastroenteritis and metformin-associated LACTIC ACIDOSIS
Education: Instruct patient to notify health care provider if malaise, myalgias, respiratory distress, somnolence, and abdominal pain.
Lispro (Vallerand & Sanoski, 2022)
MOA: Lowers blood glucose by: stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production.
S/E: HYPOGLYCEMIA
Typical dose (adult): Initial dose range – 0.2-0.6 units/kg/day. Usual maintenance range- 0.5-1.2 units/kg/day
Education: Assess for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats;
confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; HA; irritability;
nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)
Telmisartan (Vallerand & Sanoski, 2022)
MOA: Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II at various receptor sites, including vascular smooth
muscle and the adrenal glands.
S/E: ANGIOEDEMA
Typical dose (adult): 40 mg once daily
Education: Instruct patient to notify health care provider if swelling of face, eyes, lips, or tongue or difficulty swallowing or breathing
occur
, Allergies: NKDA
Last PE & Screenings: 05/2022; Colonoscopy – n/a recommended, Dental exam – 11/2022, Eye exam – 2019, EKG – 05/2022 (WNL – per patient)
Immunization Status: + children immunizations, N/A flu shot, COVID - Pfizer x 2, unknown last TDap
LMP & Birth Control (if applicable): N/A
PMH
Illnesses & Trauma: DM II, HTN, HLD
Hospitalizations/Surgeries: N/A
OB Hx/Sexual Hx: Married.
Emotional/Psy Hx: N/A
REVIEW OF SYSTEMS
General + Difficulty sleeping due to LEFT shoulder pain. Denies unintended weight loss/gain, fever, chills.
Nutrition: WNL/ denies
Skin/Hair/Nails WNL/ denies
HEENT WNL/ denies
Breasts N/A
Respiratory WNL/ denies
CV/peripheral vascular WNL/ denies
GI WNL/ denies
GU WNL/ denies
MSK + LEFT shoulder pain at rest and with movement. +limited ROM & weakness to LEFT shoulder. Denies numbness/tingling. MSK otherwise
unremarkable
Psych WNL/ denies
Neuro WNL/ denies
Lymph/Heme/Endocrine WNL/ denies
O/ Physical Exam: T: 97.9F P: 81 R: 16 BP: 130/80 HT: 68 in WT: 213lb BMI: 32.39
General Patient alert and oriented, well-groomed and has proper affect to questions being asked.
Skin Warm, dry, intact. Color appropriate to cultural background.
Head Deferred
EENT Deferred
SOAP Notes 1 and 2. CP1 & CP2
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
J.F., 50 y/o, male, independent, patient is a reliable source.
Father and Mother:
DMII & HTN
Personal/Social Hx:
Chief Complaint/RFE: Denies ETOH, tobacco
Frozen shoulder x 10 months or drug use.
Hx Present Illness: (write in paragraph format)
OLD CART
50 y/o NEW male patient presents to clinic with LEFT shoulder pain x 10 months. Patient states he was diagnosed with DM frozen
shoulder in the past. Movement exacerbates the pain and states nothing alleviates pain, despite taking OTC NSAID and RX muscle
relaxers by another physician last year. Unable to lift over 10 lb with LUE. Denies trauma, numbness or tingling. Patient takes DM II
medications and frequently checks his glucose with an average of 126.
CURRENT HEALTH
Medications: Atorvastatin 40 mg PO HS, Trujardy 5-2.5-1000 ER 2 tablets PO AM with meals, Lispro 75/25 0.2 unit/kg SUBQ BID,
telmisartan 40 mg PO QD
Atorvastatin (Vallerand & Sanoski, 2022)
MOA: Inhibits HMG-CoA reductase, an enzyme which is responsible for catalyzing an early step in the synthesis of cholesterol.
S/E: rash, abdominal cramps, constipation, diarrhea, flatus, heartburn, RHABDOMYLOSIS
Typical dose (adult): 10-20mg once daily initially
Education: Instruct patient to notify health care provider if unexplained muscle pain, tenderness, or weakness, especially if accompanied
by fever or malaise, or signs and symptoms of liver injury (fatigue, anorexia, RUQ abdominal discomfort, dark urine, jaundice) occur.
Trujardy (WCG CenterWatch, n.d.)
MOA: Combo of empagliflozin, linagliptin and metformin. Empagliflozin is a SGLT2 inhibitor and reduces renal reabsorption of filtered
glucose and lowers renal threshold for glucose and thereby increases urinary glucose excretion. Linagliptin increases the concentrations of
active incretin hormones, stimulating the release of insulin in a glucose-dependent manner and decreasing the levels of glucagon in the
circulation. Metformin is an anti-glycemic agent that decreases hepatic glucose production, decreases intestinal absorption of glucose and
improves insulin sensitivity by increasing peripheral glucose uptake and utilization.
Typical dose (adult): Take Trijardy XR 10 mg/5 mg/1000 mg or Trijardy XR 25 mg/5 mg/1000 mg as a single tablet once daily. Take
Trijardy XR 5 mg/2.5 mg/1000 mg or Trijardy XR 12.5 mg/2.5 mg/1000 mg as two tablets together once daily.
S/E: URI, UTI, gastroenteritis and metformin-associated LACTIC ACIDOSIS
Education: Instruct patient to notify health care provider if malaise, myalgias, respiratory distress, somnolence, and abdominal pain.
Lispro (Vallerand & Sanoski, 2022)
MOA: Lowers blood glucose by: stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production.
S/E: HYPOGLYCEMIA
Typical dose (adult): Initial dose range – 0.2-0.6 units/kg/day. Usual maintenance range- 0.5-1.2 units/kg/day
Education: Assess for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats;
confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; HA; irritability;
nausea; nervousness; tachycardia; tremor; weakness; unsteady gait)
Telmisartan (Vallerand & Sanoski, 2022)
MOA: Blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II at various receptor sites, including vascular smooth
muscle and the adrenal glands.
S/E: ANGIOEDEMA
Typical dose (adult): 40 mg once daily
Education: Instruct patient to notify health care provider if swelling of face, eyes, lips, or tongue or difficulty swallowing or breathing
occur
, Allergies: NKDA
Last PE & Screenings: 05/2022; Colonoscopy – n/a recommended, Dental exam – 11/2022, Eye exam – 2019, EKG – 05/2022 (WNL – per patient)
Immunization Status: + children immunizations, N/A flu shot, COVID - Pfizer x 2, unknown last TDap
LMP & Birth Control (if applicable): N/A
PMH
Illnesses & Trauma: DM II, HTN, HLD
Hospitalizations/Surgeries: N/A
OB Hx/Sexual Hx: Married.
Emotional/Psy Hx: N/A
REVIEW OF SYSTEMS
General + Difficulty sleeping due to LEFT shoulder pain. Denies unintended weight loss/gain, fever, chills.
Nutrition: WNL/ denies
Skin/Hair/Nails WNL/ denies
HEENT WNL/ denies
Breasts N/A
Respiratory WNL/ denies
CV/peripheral vascular WNL/ denies
GI WNL/ denies
GU WNL/ denies
MSK + LEFT shoulder pain at rest and with movement. +limited ROM & weakness to LEFT shoulder. Denies numbness/tingling. MSK otherwise
unremarkable
Psych WNL/ denies
Neuro WNL/ denies
Lymph/Heme/Endocrine WNL/ denies
O/ Physical Exam: T: 97.9F P: 81 R: 16 BP: 130/80 HT: 68 in WT: 213lb BMI: 32.39
General Patient alert and oriented, well-groomed and has proper affect to questions being asked.
Skin Warm, dry, intact. Color appropriate to cultural background.
Head Deferred
EENT Deferred
