MSN 650L Primary Care Residency SOAP Note 2
- Case Study With Complete Solutions 2026
Update Northern Kentucky University
Northern Kentucky University
College of Health Professions
Department of Advanced Nursing Studies
MSN 650L Section 007 – Primary Care Residency
SOAP Note 2-
Visit Date Patient Initials Age 37 Gender F Source Pt
1/25/2022 AG
Setting Office New/Established Presenting Complaint:
Established Unexplained weight gain/fatigue
, SUBJECTIVE
37-year-old patient comes into the office today with a complaint of unexplained weight
gain of 15-20 pounds since September 2021 and new onset fatigue. Patient denies
changes in dietary or exercise habits. Reviewed typical daily intake. Patient states diet
consists of coffee in the AM, lunch around 11AM and is unspecific about types of food.
Pt states she does not think she eats enough, especially for her high exercise and activity
level.
ROS:
General: positive for weight gain, denies change in appetite or exercise patterns,
positive for mild fatigue.
Skin: denies rashes, lumps, changes in hair, skin or nails.
Cardiovascular: denies chest pain, edema, hypertension, arrythmia. Positive for
intermittent palpitations.
Respiratory: denies cough, SOB, dyspnea, or cyanosis.
Neck: denies swollen glands, neck pain, enlarged thyroid.
Gastrointestinal: denies abdominal pain, reflux, nausea, vomiting, diarrhea,
constipation.
GU: denies urinary incontinence, flank pain or change in urinary habits.
Neurologic: denies numbness, tingling, seizures, memory loss.
Psychiatric: denies anxiety, depression, sleep disturbance, mood swings or suicidal
thoughts or ideations.
Endocrine: denies polyuria, polydipsia, thyroid problems
MH: hypercholesterolemia, hyperinsulinemia, acne vulgaris, palpitations, PCOS, PMS,
B12 deficiency, iron deficiency anemia
SH: hysterectomy 7/2021, ORIF humeral fx 2008
Hospitalizations: 7/2021 overnight for hyster
FH: Father alive, DM type 2, hypercholesterolemia
Mother alive, hypothyroidism, hypercholesterolemia
Social History: married, denies tobacco use, denies recreational drug use, occasional
alcohol intake (2-4 drinks per month)
Occupation: independent small business owner
Medications: Metformin HCL ER 500mg (take 2po with dinner)
Allergies: PCN
- Case Study With Complete Solutions 2026
Update Northern Kentucky University
Northern Kentucky University
College of Health Professions
Department of Advanced Nursing Studies
MSN 650L Section 007 – Primary Care Residency
SOAP Note 2-
Visit Date Patient Initials Age 37 Gender F Source Pt
1/25/2022 AG
Setting Office New/Established Presenting Complaint:
Established Unexplained weight gain/fatigue
, SUBJECTIVE
37-year-old patient comes into the office today with a complaint of unexplained weight
gain of 15-20 pounds since September 2021 and new onset fatigue. Patient denies
changes in dietary or exercise habits. Reviewed typical daily intake. Patient states diet
consists of coffee in the AM, lunch around 11AM and is unspecific about types of food.
Pt states she does not think she eats enough, especially for her high exercise and activity
level.
ROS:
General: positive for weight gain, denies change in appetite or exercise patterns,
positive for mild fatigue.
Skin: denies rashes, lumps, changes in hair, skin or nails.
Cardiovascular: denies chest pain, edema, hypertension, arrythmia. Positive for
intermittent palpitations.
Respiratory: denies cough, SOB, dyspnea, or cyanosis.
Neck: denies swollen glands, neck pain, enlarged thyroid.
Gastrointestinal: denies abdominal pain, reflux, nausea, vomiting, diarrhea,
constipation.
GU: denies urinary incontinence, flank pain or change in urinary habits.
Neurologic: denies numbness, tingling, seizures, memory loss.
Psychiatric: denies anxiety, depression, sleep disturbance, mood swings or suicidal
thoughts or ideations.
Endocrine: denies polyuria, polydipsia, thyroid problems
MH: hypercholesterolemia, hyperinsulinemia, acne vulgaris, palpitations, PCOS, PMS,
B12 deficiency, iron deficiency anemia
SH: hysterectomy 7/2021, ORIF humeral fx 2008
Hospitalizations: 7/2021 overnight for hyster
FH: Father alive, DM type 2, hypercholesterolemia
Mother alive, hypothyroidism, hypercholesterolemia
Social History: married, denies tobacco use, denies recreational drug use, occasional
alcohol intake (2-4 drinks per month)
Occupation: independent small business owner
Medications: Metformin HCL ER 500mg (take 2po with dinner)
Allergies: PCN
