SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
A.J *Patient reports that
15 years old her father has
Female hypertension which he
Patient good historian controls with meds.
*Patient reports her
mom and sister have
weight issues.
*Patient mom reports
no mental health
concerns, no diabetes,
no exposure to
communicable
diseases, no recent
travel outside the U.S,
no smokers, no stroke,
no lung disease, no
asthma, no blood
disorders, no seizures,
and no headaches
within the family.
*Patient mom reports
that the paternal
grandfather has
hypertension.
Personal/Social Hx:
Chief Complaint/RFE: A.J. is a gymnast who
Left leg pain trains five days a week
for one and a half hour
per session. Patient
reports she enjoys
running recreationally.
Patient reports no
other involvement in
Hx Present Illness: (7 Variables but do not list as such) clubs or interest.
A.J is a 15-year-old female who presents to the office with a chief complaint of left leg pain, which
started 3 days ago at her gymnastic competition following an improper landing. A.J previously
suffered an injury to the same area; no medical care was sought out for the injury. Date of last
incident not reported. Patient reports the pain is localized to the front part of her knee, and the pain is
not improved despite interventions such as application of a brace, use of crutches, and receiving
Motrin 600mg 3-4 times a day. Patient reports pain is worse at night and has difficulty bending the
affected knee when the brace is not on.
This study source was downloaded by 100000827506713 from CourseHero.com on 03-03-2023 04:56:11 GMT -06:00
https://www.coursehero.com/collection/79400176/Module-3-SOAP-note-1docx/
, CURRENT HEALTH
Medications: Patient Mom reports giving patient Motrin 600mg 3-4 times per day for 3 days. No
other medications reported.
Allergies: Patient reports no known allergies.
Last PE & Screenings: A. J reports her last PCP visit was at age 11, her vision and hearing were last
checked at that visit. A.J has not been seen by a primary care physician since her last visit.
Immunization Status: Per patient mom A. J last received her immunization vaccinations as well as
one HPV vaccine and one Hepatitis A vaccine at age 11 and is currently up to date with
immunizations. A.J receives the flu shot annually.
LMP & Birth Control (if applicable) A.J reports having monthly periods since the age of 12, with the
last menstrual period being within the past month. A.J denies birth control use and has not seen a
GYN.
PMH
Illnesses & Trauma: Patient reports no significant illness or trauma.
Hospitalizations/Surgeries: No reports of surgeries or hospitalizations.
OB Hx/Sexual Hx: Patient denies any sexual encounters. Patient states she likes boys but does not
have a boyfriend.
Emotional/Psych Hx: Patient reports no mental health concerns, however, reports recent sadness and
per patient mom patient is with a shortened temper following the recent injury.
REVIEW OF SYSTEMS
General
Nutrition- A. J reports eating a healthy diet but is thinking about becoming a vegetarian. Patient mom
with concern of lack of protein in A.J current diet. However, patient BMI concerning for obesity.
Skin/Hair/Nails- I will ask the patient if she has any concerns regarding her hair/skin/nails.
HEENT- A.J reports having no eye or vision issues, no hearing or ear pain, no headaches, no nasal
drainage, no nosebleeds, no sore throat or voice changes, no teeth or mouth issues, and no issues with
taste or smell.
Breasts- I will ask the patient if she has any concerns related to the size, development, or appearance
of her breasts.
Respiratory- I will ask the patient if she ever experiences shortness of breath or dyspnea on exertion.
CV/peripheral vascular – Patient states there are no issues with her heart, no palpitations, no chest
pain, no syncope.
GI – A.J reports no abdominal pain, no constipation or diarrhea, and reports no blood in her stool.
GU- A.J reports no issues with voiding.
MSK- A.J denies any other musculoskeletal concerns other than her left knee.
Psych- A.J reports recent sadness following the injury and expressed her frustration when she
compares her agileness and limberness to her competitors.
Neuro – Patient reports no syncope
Lymph/Heme/Endocrine
O/ Physical Exam: T: 37.0 P: 88 R: 16 BP: 110/72 HT: 5”6 WT: 70.5 kg BMI: 25.1
General- Not obtained
Skin- Not obtained
Head- Not obtained
EENT- Not obtained
Neck- Not obtained
Breasts/Chest- Not obtained
This study source was downloaded by 100000827506713 from CourseHero.com on 03-03-2023 04:56:11 GMT -06:00
https://www.coursehero.com/collection/79400176/Module-3-SOAP-note-1docx/
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
A.J *Patient reports that
15 years old her father has
Female hypertension which he
Patient good historian controls with meds.
*Patient reports her
mom and sister have
weight issues.
*Patient mom reports
no mental health
concerns, no diabetes,
no exposure to
communicable
diseases, no recent
travel outside the U.S,
no smokers, no stroke,
no lung disease, no
asthma, no blood
disorders, no seizures,
and no headaches
within the family.
*Patient mom reports
that the paternal
grandfather has
hypertension.
Personal/Social Hx:
Chief Complaint/RFE: A.J. is a gymnast who
Left leg pain trains five days a week
for one and a half hour
per session. Patient
reports she enjoys
running recreationally.
Patient reports no
other involvement in
Hx Present Illness: (7 Variables but do not list as such) clubs or interest.
A.J is a 15-year-old female who presents to the office with a chief complaint of left leg pain, which
started 3 days ago at her gymnastic competition following an improper landing. A.J previously
suffered an injury to the same area; no medical care was sought out for the injury. Date of last
incident not reported. Patient reports the pain is localized to the front part of her knee, and the pain is
not improved despite interventions such as application of a brace, use of crutches, and receiving
Motrin 600mg 3-4 times a day. Patient reports pain is worse at night and has difficulty bending the
affected knee when the brace is not on.
This study source was downloaded by 100000827506713 from CourseHero.com on 03-03-2023 04:56:11 GMT -06:00
https://www.coursehero.com/collection/79400176/Module-3-SOAP-note-1docx/
, CURRENT HEALTH
Medications: Patient Mom reports giving patient Motrin 600mg 3-4 times per day for 3 days. No
other medications reported.
Allergies: Patient reports no known allergies.
Last PE & Screenings: A. J reports her last PCP visit was at age 11, her vision and hearing were last
checked at that visit. A.J has not been seen by a primary care physician since her last visit.
Immunization Status: Per patient mom A. J last received her immunization vaccinations as well as
one HPV vaccine and one Hepatitis A vaccine at age 11 and is currently up to date with
immunizations. A.J receives the flu shot annually.
LMP & Birth Control (if applicable) A.J reports having monthly periods since the age of 12, with the
last menstrual period being within the past month. A.J denies birth control use and has not seen a
GYN.
PMH
Illnesses & Trauma: Patient reports no significant illness or trauma.
Hospitalizations/Surgeries: No reports of surgeries or hospitalizations.
OB Hx/Sexual Hx: Patient denies any sexual encounters. Patient states she likes boys but does not
have a boyfriend.
Emotional/Psych Hx: Patient reports no mental health concerns, however, reports recent sadness and
per patient mom patient is with a shortened temper following the recent injury.
REVIEW OF SYSTEMS
General
Nutrition- A. J reports eating a healthy diet but is thinking about becoming a vegetarian. Patient mom
with concern of lack of protein in A.J current diet. However, patient BMI concerning for obesity.
Skin/Hair/Nails- I will ask the patient if she has any concerns regarding her hair/skin/nails.
HEENT- A.J reports having no eye or vision issues, no hearing or ear pain, no headaches, no nasal
drainage, no nosebleeds, no sore throat or voice changes, no teeth or mouth issues, and no issues with
taste or smell.
Breasts- I will ask the patient if she has any concerns related to the size, development, or appearance
of her breasts.
Respiratory- I will ask the patient if she ever experiences shortness of breath or dyspnea on exertion.
CV/peripheral vascular – Patient states there are no issues with her heart, no palpitations, no chest
pain, no syncope.
GI – A.J reports no abdominal pain, no constipation or diarrhea, and reports no blood in her stool.
GU- A.J reports no issues with voiding.
MSK- A.J denies any other musculoskeletal concerns other than her left knee.
Psych- A.J reports recent sadness following the injury and expressed her frustration when she
compares her agileness and limberness to her competitors.
Neuro – Patient reports no syncope
Lymph/Heme/Endocrine
O/ Physical Exam: T: 37.0 P: 88 R: 16 BP: 110/72 HT: 5”6 WT: 70.5 kg BMI: 25.1
General- Not obtained
Skin- Not obtained
Head- Not obtained
EENT- Not obtained
Neck- Not obtained
Breasts/Chest- Not obtained
This study source was downloaded by 100000827506713 from CourseHero.com on 03-03-2023 04:56:11 GMT -06:00
https://www.coursehero.com/collection/79400176/Module-3-SOAP-note-1docx/
