WCU Adult Gero SOAP Note
Demographic Data
Age: 45 years old.
Gender: Female
Subjective
Chief Complaint (CC)
"My muscles ache, and my throat hurts a lot. I have also had a fever of 100.6°F since
yesterday."
History of Present Illness (HPI)
Onset: Symptoms started on February 10, 2024.
Location/Radiation: Muscles and throat.
Duration: Since onset.
Character: Aching and soreness.
Aggravating factors: fever.
Relieving factors: not specified.
Timing: Symptoms persist since onset.
Severity: fever of 100.6°F.
Past medical history:
Hypertension
Diabetes Mellitus Type 2 (diagnosed in 2010)
Hyperlipidemia
Past Surgical History:
Appendectomy: April 15, 2005
, Cholecystectomy, July 20, 2012
FAMILY HISTORY:
Mother: Hypertension, Diabetes Mellitus
Father: Hyperlipidemia
Sister: None reported
Current Medications:
Lisinopril 10mg, orally, daily (since 2020)
Metformin 1000mg, orally, twice daily (since 2020)
Simvastatin 20mg, orally, nightly (since 2022)
ALLERGIES:
Penicillin (hives): reported in 2003
Sulfa drugs (Rash): reported in 2008
Immunizations History:
up-to-date on routine immunizations.
Health Maintenance:
Annual physical examination (last done on May 3, 2023)
Annual eye examination for diabetic retinopathy screening (last done on April 25, 2023)
Annual lipid panel (last done on September 15, 2023)
SOCIAL HISTORY:
Home And Environment: She lives in a single-family home with her spouse. There were
no reported environmental concerns.
Education/Employment: Retired teacher. There is no current employment. Completed a
bachelor's degree in education.
Activities: engages in daily walks for exercise. Enjoys gardening and reading.
Demographic Data
Age: 45 years old.
Gender: Female
Subjective
Chief Complaint (CC)
"My muscles ache, and my throat hurts a lot. I have also had a fever of 100.6°F since
yesterday."
History of Present Illness (HPI)
Onset: Symptoms started on February 10, 2024.
Location/Radiation: Muscles and throat.
Duration: Since onset.
Character: Aching and soreness.
Aggravating factors: fever.
Relieving factors: not specified.
Timing: Symptoms persist since onset.
Severity: fever of 100.6°F.
Past medical history:
Hypertension
Diabetes Mellitus Type 2 (diagnosed in 2010)
Hyperlipidemia
Past Surgical History:
Appendectomy: April 15, 2005
, Cholecystectomy, July 20, 2012
FAMILY HISTORY:
Mother: Hypertension, Diabetes Mellitus
Father: Hyperlipidemia
Sister: None reported
Current Medications:
Lisinopril 10mg, orally, daily (since 2020)
Metformin 1000mg, orally, twice daily (since 2020)
Simvastatin 20mg, orally, nightly (since 2022)
ALLERGIES:
Penicillin (hives): reported in 2003
Sulfa drugs (Rash): reported in 2008
Immunizations History:
up-to-date on routine immunizations.
Health Maintenance:
Annual physical examination (last done on May 3, 2023)
Annual eye examination for diabetic retinopathy screening (last done on April 25, 2023)
Annual lipid panel (last done on September 15, 2023)
SOCIAL HISTORY:
Home And Environment: She lives in a single-family home with her spouse. There were
no reported environmental concerns.
Education/Employment: Retired teacher. There is no current employment. Completed a
bachelor's degree in education.
Activities: engages in daily walks for exercise. Enjoys gardening and reading.
