SOAP Note 4 Name:
Typhon Encounter #:
NU 610:7G Comprehensive: X
Herzing University
S: SUBJECTIVE DATA
CC: Annual Physical Exam
HPI: A 36-year-old Caucasian male presents for annual physical exam
PMH: Hypothyroid
Bicep repair surgery - 2022
ALLERGIES Tylenol – rash, hives
MEDICATIONS Thyroid Armour – 6omg tablet once daily
Testosterone cypionate – 200mg intramuscular once weekly
SH College graduate, currently working as a law enforcement deputy.
Pt is single and has no kids.
Sexually active
Exercises 5-6 times per week
Denies illicit drug and tobacco use
Drinks alcohol socially – one to two beers per month
FH Father – type 2 diabetes mellitus, diet controlled; prostate cancer, in
remission
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 Last health visit was September 2024
Up-to-date on all health maintenance for his age
ROS Constitutional Denies fever, chills, or weight
changes
(put N/A in sections Head Denies headaches
not completed day of
exam) Eyes Denies visual changes,
photophobia
Ears, Nose, Mouth, Throat Denies sore throat, hearing
problems, dental problems, or
sinus congestion
Neck Denies any neck pain or stiffness
Cardiovascular/Peripheral Denies chest pain, palpitations,
Vascular or swelling.
Respiratory Denies shortness of breath,
coughing, or wheezing.
Breast N/A
Gastrointestinal Denies any abdominal pain,
distension, constipation, nausea,
, SOAP Note 4 Name:
Typhon Encounter #:
NU 610:7G Comprehensive: X
Herzing University
vomiting, diarrhea, or appetite
changes.
Genitourinary Denies any changes in urine
output or frequency. Denies
difficulty urinating, urgency, or
flank pain.
Musculoskeletal Denies joint pain, swelling, or
stiffness. Denies any muscle pain
or weakness.
Integumentary Denies any changes, rashes, or
itching.
Neurological Denies numbness, tingling,
headaches, light-headedness, or
dizziness.
Psychiatric (screening tools: Ex: Denies anxiety, depression,
PHQ-9, MMSE, GAD-7)
difficulty concentrating, sleep
disturbances, suicidal or
homicidal ideations
Endocrine Denies any heat or cold
intolerance
Hematologic/Lymphatic N/A
Allergic/Immunologic Allergy to acetaminophen
Other N/A
O: OBJECTIVE DATA
VITALS: HR: 75 RR: 16 BP: 124/89 Temp: 98.3
SpO2%: Ht: 5’10” Wt: 210lbs BMI: 30.1
Age: 36 yo LMP: N/A PAIN: 0/10
PHYSICAL General Appearance No acute distress, well
EXAM developed, appears stated age
Head Normocephalic, symmetrical
(Pertinent data Eyes PERRLA, negative nystagmus
related to
presenting
ENT, Mouth Ear canal non-tender, no
problem or swelling noted
visit type. Put Nasal mucosa pink and moist
N/A in Moist mucous membranes
sections
Typhon Encounter #:
NU 610:7G Comprehensive: X
Herzing University
S: SUBJECTIVE DATA
CC: Annual Physical Exam
HPI: A 36-year-old Caucasian male presents for annual physical exam
PMH: Hypothyroid
Bicep repair surgery - 2022
ALLERGIES Tylenol – rash, hives
MEDICATIONS Thyroid Armour – 6omg tablet once daily
Testosterone cypionate – 200mg intramuscular once weekly
SH College graduate, currently working as a law enforcement deputy.
Pt is single and has no kids.
Sexually active
Exercises 5-6 times per week
Denies illicit drug and tobacco use
Drinks alcohol socially – one to two beers per month
FH Father – type 2 diabetes mellitus, diet controlled; prostate cancer, in
remission
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 Last health visit was September 2024
Up-to-date on all health maintenance for his age
ROS Constitutional Denies fever, chills, or weight
changes
(put N/A in sections Head Denies headaches
not completed day of
exam) Eyes Denies visual changes,
photophobia
Ears, Nose, Mouth, Throat Denies sore throat, hearing
problems, dental problems, or
sinus congestion
Neck Denies any neck pain or stiffness
Cardiovascular/Peripheral Denies chest pain, palpitations,
Vascular or swelling.
Respiratory Denies shortness of breath,
coughing, or wheezing.
Breast N/A
Gastrointestinal Denies any abdominal pain,
distension, constipation, nausea,
, SOAP Note 4 Name:
Typhon Encounter #:
NU 610:7G Comprehensive: X
Herzing University
vomiting, diarrhea, or appetite
changes.
Genitourinary Denies any changes in urine
output or frequency. Denies
difficulty urinating, urgency, or
flank pain.
Musculoskeletal Denies joint pain, swelling, or
stiffness. Denies any muscle pain
or weakness.
Integumentary Denies any changes, rashes, or
itching.
Neurological Denies numbness, tingling,
headaches, light-headedness, or
dizziness.
Psychiatric (screening tools: Ex: Denies anxiety, depression,
PHQ-9, MMSE, GAD-7)
difficulty concentrating, sleep
disturbances, suicidal or
homicidal ideations
Endocrine Denies any heat or cold
intolerance
Hematologic/Lymphatic N/A
Allergic/Immunologic Allergy to acetaminophen
Other N/A
O: OBJECTIVE DATA
VITALS: HR: 75 RR: 16 BP: 124/89 Temp: 98.3
SpO2%: Ht: 5’10” Wt: 210lbs BMI: 30.1
Age: 36 yo LMP: N/A PAIN: 0/10
PHYSICAL General Appearance No acute distress, well
EXAM developed, appears stated age
Head Normocephalic, symmetrical
(Pertinent data Eyes PERRLA, negative nystagmus
related to
presenting
ENT, Mouth Ear canal non-tender, no
problem or swelling noted
visit type. Put Nasal mucosa pink and moist
N/A in Moist mucous membranes
sections
