SOAP Note Format - KATIE
Patient Information: Katie, 65 y/o Caucasian female.
S.
CC: “lack of energy”
HPI: Patient says she is normally healthy but presents to clinic today with a chief
complaint of “lack of energy”.
Onset: 1 month
Location: generalized
Duration: non-specified
Characteristics: lack of sleep, decreased pleasure in performing usual daily activities,
helplessness
Aggravating Factors: none reported
Relieving Factors: None reported
Treatment: None reported
Current Medications:
· Daily multivitamin
· Evista (osteoporosis)
· HCTZ (for hypertension)
Allergies: NKDA. Seasonal allergies to pollen and reports hayfever.
PMHx: Childhood history of chicken pox, measles & rubella. Current history HTN &
HLD. PSHx: Tonsillectomy & Cholecystectomy. Hospitalized for surgeries and
childbirth
Soc Hx: Married to John and they both live with married daughter and her family. Takes
care of the kids while their parents work. Her husband and son, Patrick, both smoke “but
not in the house”. Denies any alcohol or tobacco use.
Fam Hx: Non-contributory. Parents died of “old age” and siblings are well with same
HTN problems.
ROS:
CONSTITUTIONAL: 6lb weight loss in 1month. Denies fever or chills Endorses
weakness and fatigue.
SKIN: No rash or itching.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: c/o cough, non-productive, soreness on right side with cough and deep
This study source was downloaded by 100000827929844 from CourseHero.com on 07-13-2022 07:45:33 GMT -05:00
https://www.coursehero.com/file/55759491/NR-511-Wk-7-Katie-SOAP-Note/
Patient Information: Katie, 65 y/o Caucasian female.
S.
CC: “lack of energy”
HPI: Patient says she is normally healthy but presents to clinic today with a chief
complaint of “lack of energy”.
Onset: 1 month
Location: generalized
Duration: non-specified
Characteristics: lack of sleep, decreased pleasure in performing usual daily activities,
helplessness
Aggravating Factors: none reported
Relieving Factors: None reported
Treatment: None reported
Current Medications:
· Daily multivitamin
· Evista (osteoporosis)
· HCTZ (for hypertension)
Allergies: NKDA. Seasonal allergies to pollen and reports hayfever.
PMHx: Childhood history of chicken pox, measles & rubella. Current history HTN &
HLD. PSHx: Tonsillectomy & Cholecystectomy. Hospitalized for surgeries and
childbirth
Soc Hx: Married to John and they both live with married daughter and her family. Takes
care of the kids while their parents work. Her husband and son, Patrick, both smoke “but
not in the house”. Denies any alcohol or tobacco use.
Fam Hx: Non-contributory. Parents died of “old age” and siblings are well with same
HTN problems.
ROS:
CONSTITUTIONAL: 6lb weight loss in 1month. Denies fever or chills Endorses
weakness and fatigue.
SKIN: No rash or itching.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations
or edema.
RESPIRATORY: c/o cough, non-productive, soreness on right side with cough and deep
This study source was downloaded by 100000827929844 from CourseHero.com on 07-13-2022 07:45:33 GMT -05:00
https://www.coursehero.com/file/55759491/NR-511-Wk-7-Katie-SOAP-Note/
