NURS 5337 SOAP Note Form CP1 & CP2 | 2026 Edition | Complete Solutions & Explanations | University of Texas, Arlington
SOAP Note Form CP1 & CP2
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
G.C. is a 73-year-old Hispanic female. She is a reliable source. Father passed
from prostate CA
at 80
Mother’s history
of CAD and
Personal/Social
Chief Concern/RFE: Former middle
“My blood pressure is very high and I am anxious” school teacher.
Lives with
husband. Does
not smoke. Does
not drink.
Hx Present Illness: (write in paragraph format)
HPI:
Patient presents to the clinic with complaints of high blood pressure started four days ago after drinking coffee.
She is currently complaining of pulsing headache 7/10. She states that she "having family problems and I have
to take care of my grandkids". Patient has history of morbid obesity, OSA, type 2 DM, and hyperlipidemia.
Additionally, she reports that she is compliant with her C-pap machine. Patient states that her home BP for the
past 2 days were 150-160 systolic over 75.
CURRENT HEALTH
Medications: docusate sodium 100mg oral daily, simvastatin 20 mg oral daily, glipizide 5 mg po two times a day,
semaglutide 1 mg each week
Allergies: no known allergies
Last PE & Screenings: physical 5/15/23, colonoscopy neg 2019
Immunization Status: influenza vaccine September 2023, Covid-19 vaccine 2021
LMP & Birth Control (if applicable) N/A
PMH
Illnesses & Trauma: Sleep apnea, obstructive sleep apnea, hyperlipidemia, morbidly obese, type 2 DM
Hospitalizations/Surgeries: umbilical hernia repair 2015, gallbladder removal 1999, right eye cataract surgery
2018
OB Hx/Sexual Hx: monogamous with husband, Gravida 3, Para 3
Emotional/Psy Hx: “I’ve only had anxiety now.”
REVIEW OF SYSTEMS
General: The patient denies fever, night sweats, weight changes, complains of fatigue.
Nutrition: reports decreased appetite, denies nausea, and diarrhea, has occasional constipation
Skin/Hair/Nails: No rashes, lesions, open wound or bites, no other skin abnormalities reported
, HEENT: The patient reported no recent head trauma, dizziness, or lightheadedness. There was no history of
seizures or loss of consciousness. The patient did not experience any visual disturbances, eye pain, redness, itching,
or discharge. They also had no hearing loss, tinnitus, or ear pain. The patient denied any nasal congestion,
discharge, or sinus pain; no complaints of a sore throat, difficulty swallowing, voice changes, or persistent cough.
Breasts: denies masses or pain
Respiratory: No respiratory symptoms reported, except for a history of sleep apnea
CV/peripheral vascular: No chest pain, no palpitations, no edema, no shortness of breath on exertion
GI : denies nausea and diarrhea, no dysphagia, and no heartburn.
GU: No hematuria and no increase in urinary frequency. No dysuria.
MSK: Ambulates well, no falls. Denies pain or difficulty with ambulating.
Psych: Reports intermittent anxiety when blood pressure is high , no insomnia
Neuro: No dizziness, no vertigo, no fainting, no motor disturbances, and no sensory disturbances
Lymph/Heme/Endocrine: No polydipsia, no excessive sweating.
O/ Physical Exam: T: 97.1 F P: 67 bpm R: 18 BP: 169/70 HT: 59 inches WT: 167 lbs
BMI: 36.1 (obese)
General: Alert, well groomed, well developed, in no acute distress.
Skin: Warm, dry, pink, no lesions, or masses noted. Body is warm to touch, good turgor, and no brittle nails and
clubbing noted.
Head; Normocephalic, atraumatic. Denies any tenderness with palpation.
EENT: Pupils are equal, round and reactive to light, pale conjunctiva. No discharge noted. Oral mucosa pink and
moist. No pharyngeal erythema or exudates noted.
Neck: Supple, and trachea midline. No tenderness, lymphadenopathy, or lesions noted.
Breasts/Chest: No tenderness on palpation.
Lungs: Lungs are clear and equal to auscultation. Respirations are unlabored, regular, and with symmetric chest
wall expansion.
Heart/ perip vascular: S1, S2 auscultated with no murmurs noted. Heart rate is regular with no irregularities.
Capillary refill is less than 3 seconds with normal peripheral perfusion. No edema noted. No peripheral edema
noted
Abdomen: Hyperactive bowel sounds are noted in all quadrants, no tenderness on palpation, no hepatomegaly, no
splenomegaly, old scar from open cholecystectomy
Genitalia/Rectum: deferred this assessment
Lymph: no palpable lymph nodes
MSK: ROM intact for all extremities, gait steady, negative pronator drift
SOAP Note Form CP1 & CP2
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
G.C. is a 73-year-old Hispanic female. She is a reliable source. Father passed
from prostate CA
at 80
Mother’s history
of CAD and
Personal/Social
Chief Concern/RFE: Former middle
“My blood pressure is very high and I am anxious” school teacher.
Lives with
husband. Does
not smoke. Does
not drink.
Hx Present Illness: (write in paragraph format)
HPI:
Patient presents to the clinic with complaints of high blood pressure started four days ago after drinking coffee.
She is currently complaining of pulsing headache 7/10. She states that she "having family problems and I have
to take care of my grandkids". Patient has history of morbid obesity, OSA, type 2 DM, and hyperlipidemia.
Additionally, she reports that she is compliant with her C-pap machine. Patient states that her home BP for the
past 2 days were 150-160 systolic over 75.
CURRENT HEALTH
Medications: docusate sodium 100mg oral daily, simvastatin 20 mg oral daily, glipizide 5 mg po two times a day,
semaglutide 1 mg each week
Allergies: no known allergies
Last PE & Screenings: physical 5/15/23, colonoscopy neg 2019
Immunization Status: influenza vaccine September 2023, Covid-19 vaccine 2021
LMP & Birth Control (if applicable) N/A
PMH
Illnesses & Trauma: Sleep apnea, obstructive sleep apnea, hyperlipidemia, morbidly obese, type 2 DM
Hospitalizations/Surgeries: umbilical hernia repair 2015, gallbladder removal 1999, right eye cataract surgery
2018
OB Hx/Sexual Hx: monogamous with husband, Gravida 3, Para 3
Emotional/Psy Hx: “I’ve only had anxiety now.”
REVIEW OF SYSTEMS
General: The patient denies fever, night sweats, weight changes, complains of fatigue.
Nutrition: reports decreased appetite, denies nausea, and diarrhea, has occasional constipation
Skin/Hair/Nails: No rashes, lesions, open wound or bites, no other skin abnormalities reported
, HEENT: The patient reported no recent head trauma, dizziness, or lightheadedness. There was no history of
seizures or loss of consciousness. The patient did not experience any visual disturbances, eye pain, redness, itching,
or discharge. They also had no hearing loss, tinnitus, or ear pain. The patient denied any nasal congestion,
discharge, or sinus pain; no complaints of a sore throat, difficulty swallowing, voice changes, or persistent cough.
Breasts: denies masses or pain
Respiratory: No respiratory symptoms reported, except for a history of sleep apnea
CV/peripheral vascular: No chest pain, no palpitations, no edema, no shortness of breath on exertion
GI : denies nausea and diarrhea, no dysphagia, and no heartburn.
GU: No hematuria and no increase in urinary frequency. No dysuria.
MSK: Ambulates well, no falls. Denies pain or difficulty with ambulating.
Psych: Reports intermittent anxiety when blood pressure is high , no insomnia
Neuro: No dizziness, no vertigo, no fainting, no motor disturbances, and no sensory disturbances
Lymph/Heme/Endocrine: No polydipsia, no excessive sweating.
O/ Physical Exam: T: 97.1 F P: 67 bpm R: 18 BP: 169/70 HT: 59 inches WT: 167 lbs
BMI: 36.1 (obese)
General: Alert, well groomed, well developed, in no acute distress.
Skin: Warm, dry, pink, no lesions, or masses noted. Body is warm to touch, good turgor, and no brittle nails and
clubbing noted.
Head; Normocephalic, atraumatic. Denies any tenderness with palpation.
EENT: Pupils are equal, round and reactive to light, pale conjunctiva. No discharge noted. Oral mucosa pink and
moist. No pharyngeal erythema or exudates noted.
Neck: Supple, and trachea midline. No tenderness, lymphadenopathy, or lesions noted.
Breasts/Chest: No tenderness on palpation.
Lungs: Lungs are clear and equal to auscultation. Respirations are unlabored, regular, and with symmetric chest
wall expansion.
Heart/ perip vascular: S1, S2 auscultated with no murmurs noted. Heart rate is regular with no irregularities.
Capillary refill is less than 3 seconds with normal peripheral perfusion. No edema noted. No peripheral edema
noted
Abdomen: Hyperactive bowel sounds are noted in all quadrants, no tenderness on palpation, no hepatomegaly, no
splenomegaly, old scar from open cholecystectomy
Genitalia/Rectum: deferred this assessment
Lymph: no palpable lymph nodes
MSK: ROM intact for all extremities, gait steady, negative pronator drift
