SOAP Note 2 Name:
Typhon Encounter #:
NU 610:7G Comprehensive: X
Herzing University
S: SUBJECTIVE DATA
CC: Comprehensive exam
HPI: A 36-year-old caucasian male presents for physical exam. He reports
currently having intermittent mild lower back pain. Reports the pain
started several years ago and improves with a massage or ibuprofen. Pain
is described as pressure and throbbing sensation. Aggravating factors
include strenuous activity and remaining in the same position for too long.
Alleviating factors include massage and over the counter ibuprofen.
PMH: Hypothyroid
Bicep repair surgery - 2022
Hypogonadism
ALLERGIES Tylenol – rash, hives
MEDICATIONS Thyroid Armour – 6omg tablet once daily
Testosterone cypionate – 200mg intramuscular once weekly
Tadalafil – 10mg tablet once daily
SH Law enforcement deputy
Sexually active
FH Father – type 2 diabetes mellitus, diet controlled
Mother – type 2 diabetes mellitus, diet controlled
HEALTH Required for all SOAP notes:
PROMOTION & Diet – low carb, high protein
MAINTENANC Exercises 5-6 times per week
E Denies illicit drug and tobacco use
Drinks alcohol socially – one to two beers per month
Last health visit was September 2024
Up-to-date on health maintenance for his age
ROS Constitutional
Head
(put N/A in sections Eyes
not completed day of
exam)
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral
Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary
Musculoskeletal
Typhon Encounter #:
NU 610:7G Comprehensive: X
Herzing University
S: SUBJECTIVE DATA
CC: Comprehensive exam
HPI: A 36-year-old caucasian male presents for physical exam. He reports
currently having intermittent mild lower back pain. Reports the pain
started several years ago and improves with a massage or ibuprofen. Pain
is described as pressure and throbbing sensation. Aggravating factors
include strenuous activity and remaining in the same position for too long.
Alleviating factors include massage and over the counter ibuprofen.
PMH: Hypothyroid
Bicep repair surgery - 2022
Hypogonadism
ALLERGIES Tylenol – rash, hives
MEDICATIONS Thyroid Armour – 6omg tablet once daily
Testosterone cypionate – 200mg intramuscular once weekly
Tadalafil – 10mg tablet once daily
SH Law enforcement deputy
Sexually active
FH Father – type 2 diabetes mellitus, diet controlled
Mother – type 2 diabetes mellitus, diet controlled
HEALTH Required for all SOAP notes:
PROMOTION & Diet – low carb, high protein
MAINTENANC Exercises 5-6 times per week
E Denies illicit drug and tobacco use
Drinks alcohol socially – one to two beers per month
Last health visit was September 2024
Up-to-date on health maintenance for his age
ROS Constitutional
Head
(put N/A in sections Eyes
not completed day of
exam)
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral
Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary
Musculoskeletal
