SOAP Note
https://frc.shadowhealth.com/wp-
content/uploads/2016/02/05_Gatrointestinal-
TinaAbnormalsGraduateFall2015.pdf
Greeting
Tina Jones is a 28 year old African American female. She is single and lives with her mother.
Tina is the primary source of her health is tree and has offered the information of her own free
will. Tina speaks english and her speech is clear and coherent. During the interview Tina has
maintained good eye contact.
General Survey
This is Tina Jones. She is a 28 year old, african american female. Tina appears to be well
groomed and well dressed. Tina is alert and oriented to her surroundings. Tina weighs 90 kg and
is 170 cm, with a BMI of 31. Tina's facial features are symmetrical with movement and there are
no overall signs of acute distress. Based on appearance and body mass index Tina appears to be
overweight. Tina's body parts appear to be equal bilaterally and are relevant in proportion to her
body. Tina appears to have good posture and a sitting comfortably on the table. Rang of motion
and gate seems normal. Tina has appropriate facial expressions mood and affect speech speech
patterns and dress all seemed normal and appropriate for her age.
S:
CC: “ Patient is in the office today for "scrape on my foot...it's looking pretty nasty. and
the pain is killing me!"
o EMPATHY!!!!!!
HPI:
o Onset:.
o Location:
o Duration:
o Characteristics/description:
o Aggravating factors:
o Relieving factors:
o Treatment:
o Current pain/pain at its worst (pain scale
o EDUCATION!!!!
Current Meds:
o What? Why?Dose,Frequency, Started when?Last time taken, Help the diagnosis?
, o Allbuterol inhaler 90mcg/spray last used three days ago. Tina stated that she uses
her inhaler PRN and has needed to use it two to three thimes a week recently.Tina
is taking Tramadol 50 mg three times a day, last taken this morning around 830.
Tina stated that this helps control the pain for a few hours. Tina takes
Acetaminophen 500-1000 mg PO prn for hear headaches.Tina denies taking any
supplements, herbs or viatamins on a daily bases. Tina uses Neosporine on her
right foot. Tina take Advil 200mg PRN for menstral cramps.Any vitamins? Denies
o Supplements? Denies
o Herbs? Denies
o EDUCATION!!!!! And “Thank you for telling me about your meds…”
Allergies:
o Meds: PCN reaction rash and hives.
o Environmental: Tina is allergic to cats. She gets itchy eyes, sneezing and stated
that her “asthma acts up” around them
o Latex: Tina denies a latex allergy.
o What happens?
o When discovered?
o How treated?
o Eczema : denies
PMH:
o When dx’d? Asthma at 2 1/2 years old, Diabetes at 24 years old
o How managed?
o Last “flare-up/episode”
o Describe symptoms
o Hospitalizations: Went to the ER one week ago for her injury to her right foot.
Prior to that she has only been to the hospital for asthma attacks. The first
Asthma attack was when she was 16 years old. Tina stated that she has been to
the hospital “maybe five times total” for her asthma.
o Triggers/aggravating factors
o Sx
o EDUCATION/EMPATHY!!!! ESPECIALLY WITH T2DM/BLOOD SUGAR CHECKS, ETC.
And “Thank you for telling me about your history…”
Social Hx:
o Education level: Tina is in school for her Bachelor’s degree in Accounting.
o Living situation: Tina has recently moved back in with her mother following the
death of Tina’s father.
o Stressors/current stress level: Tina stated “I feel pretty worried about my foot”,
this is causing some stress in her life due missing school and work due to
o Religious affiliation: Tina is very active in her church.
o Activity level:
Regular exercise
o Occupation: Tina has works since highschool as a supervisor at Mid-American
Copy and ship. She stated she works 32 hours a week and is sometimes flexed
, Hrs worked
o Diet/nutrition:
Last meal
What?
When?
Usual daily food
Salt intake
Caffeine intake
Recent diet changes
Appetite
Sodas
o Substance use:
EDUCATION!!!!!!
Illicit drugs: Denies
What: Smoked pot
First tried when? 15 years old
How often used? Every weekend but hasent done it in “a long
time”
Last used? At age 20 or 21
Alcohol
How much? She is social drinker of alcohol. She stated no more
than two to three in a sitting.
First tried when? In high school around age 15 or 16
Last drank? At least 3 weeks ago
Cigarettes/tobacco: Denies
Ever?
When?
How much?
Last one?
Desire to quit?
o Health maintenance:
EDUCATION!!!!
Immunizations
Tetanus: Received a tetanus booster about a year ago.
Childhood imm: Received a hepatitis vaccination but is unsure it is
was hepatitis A or B that she received. Received the meningitis
vaccine at 19 years of age. All childhood immunizations she stated
she was “pretty sure:” she got. Stated she had the chicken pox and
therefore did not need to get vaccinated.
Flu vax
Sunscreen/exposure: Tina denies uses sunscreen when outdoors but
stated she would use “if I went swimming”.
https://frc.shadowhealth.com/wp-
content/uploads/2016/02/05_Gatrointestinal-
TinaAbnormalsGraduateFall2015.pdf
Greeting
Tina Jones is a 28 year old African American female. She is single and lives with her mother.
Tina is the primary source of her health is tree and has offered the information of her own free
will. Tina speaks english and her speech is clear and coherent. During the interview Tina has
maintained good eye contact.
General Survey
This is Tina Jones. She is a 28 year old, african american female. Tina appears to be well
groomed and well dressed. Tina is alert and oriented to her surroundings. Tina weighs 90 kg and
is 170 cm, with a BMI of 31. Tina's facial features are symmetrical with movement and there are
no overall signs of acute distress. Based on appearance and body mass index Tina appears to be
overweight. Tina's body parts appear to be equal bilaterally and are relevant in proportion to her
body. Tina appears to have good posture and a sitting comfortably on the table. Rang of motion
and gate seems normal. Tina has appropriate facial expressions mood and affect speech speech
patterns and dress all seemed normal and appropriate for her age.
S:
CC: “ Patient is in the office today for "scrape on my foot...it's looking pretty nasty. and
the pain is killing me!"
o EMPATHY!!!!!!
HPI:
o Onset:.
o Location:
o Duration:
o Characteristics/description:
o Aggravating factors:
o Relieving factors:
o Treatment:
o Current pain/pain at its worst (pain scale
o EDUCATION!!!!
Current Meds:
o What? Why?Dose,Frequency, Started when?Last time taken, Help the diagnosis?
, o Allbuterol inhaler 90mcg/spray last used three days ago. Tina stated that she uses
her inhaler PRN and has needed to use it two to three thimes a week recently.Tina
is taking Tramadol 50 mg three times a day, last taken this morning around 830.
Tina stated that this helps control the pain for a few hours. Tina takes
Acetaminophen 500-1000 mg PO prn for hear headaches.Tina denies taking any
supplements, herbs or viatamins on a daily bases. Tina uses Neosporine on her
right foot. Tina take Advil 200mg PRN for menstral cramps.Any vitamins? Denies
o Supplements? Denies
o Herbs? Denies
o EDUCATION!!!!! And “Thank you for telling me about your meds…”
Allergies:
o Meds: PCN reaction rash and hives.
o Environmental: Tina is allergic to cats. She gets itchy eyes, sneezing and stated
that her “asthma acts up” around them
o Latex: Tina denies a latex allergy.
o What happens?
o When discovered?
o How treated?
o Eczema : denies
PMH:
o When dx’d? Asthma at 2 1/2 years old, Diabetes at 24 years old
o How managed?
o Last “flare-up/episode”
o Describe symptoms
o Hospitalizations: Went to the ER one week ago for her injury to her right foot.
Prior to that she has only been to the hospital for asthma attacks. The first
Asthma attack was when she was 16 years old. Tina stated that she has been to
the hospital “maybe five times total” for her asthma.
o Triggers/aggravating factors
o Sx
o EDUCATION/EMPATHY!!!! ESPECIALLY WITH T2DM/BLOOD SUGAR CHECKS, ETC.
And “Thank you for telling me about your history…”
Social Hx:
o Education level: Tina is in school for her Bachelor’s degree in Accounting.
o Living situation: Tina has recently moved back in with her mother following the
death of Tina’s father.
o Stressors/current stress level: Tina stated “I feel pretty worried about my foot”,
this is causing some stress in her life due missing school and work due to
o Religious affiliation: Tina is very active in her church.
o Activity level:
Regular exercise
o Occupation: Tina has works since highschool as a supervisor at Mid-American
Copy and ship. She stated she works 32 hours a week and is sometimes flexed
, Hrs worked
o Diet/nutrition:
Last meal
What?
When?
Usual daily food
Salt intake
Caffeine intake
Recent diet changes
Appetite
Sodas
o Substance use:
EDUCATION!!!!!!
Illicit drugs: Denies
What: Smoked pot
First tried when? 15 years old
How often used? Every weekend but hasent done it in “a long
time”
Last used? At age 20 or 21
Alcohol
How much? She is social drinker of alcohol. She stated no more
than two to three in a sitting.
First tried when? In high school around age 15 or 16
Last drank? At least 3 weeks ago
Cigarettes/tobacco: Denies
Ever?
When?
How much?
Last one?
Desire to quit?
o Health maintenance:
EDUCATION!!!!
Immunizations
Tetanus: Received a tetanus booster about a year ago.
Childhood imm: Received a hepatitis vaccination but is unsure it is
was hepatitis A or B that she received. Received the meningitis
vaccine at 19 years of age. All childhood immunizations she stated
she was “pretty sure:” she got. Stated she had the chicken pox and
therefore did not need to get vaccinated.
Flu vax
Sunscreen/exposure: Tina denies uses sunscreen when outdoors but
stated she would use “if I went swimming”.
