SOAP NOTE
Student Name: Course: NSG6430
Name: K.P. Date: 04/02/24 Time: 1130
Ethnicity: White Age: 51 Sex: F
SUBJECTIVE
CC: “I have a couple of painless lumps on my right breast.”
HPI: A 51-year-old white female patient presents with a chief complaint of two painless
right-breast lumps that she detected four months ago. She denies any recent or past breast
trauma, breast discharge, bleeding, or overlying skin changes.
Medications: (list with reason for med )
Metoprolol 25mg twice a day
Furosemide 20mg daily 3 times a week
Metformin 500mg twice a day
PMH
Allergies: Penicillin- rash
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, type 2 diabetes, CHF
Hospitalizations/Surgeries- 3 cesareans, hysterectomy
Family History
M: Alive- 80 years old- Hypertension, hyperlipidemia, stroke
F: Unknown
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:52 GMT -05:00
https://www.coursehero.com/file/235913183/NSG6430-Week-8-SOAP-Costa-Cdocx/
, Social History
The patient is a non-smoker and consumes alcohol occasionally, with a balanced diet and
regular moderate exercise routine. She lives with her husband and two adult children,
maintaining good social support and family relationships.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies dyspnea or cough
Eyes Gastrointestinal
Deferred Deferred
Ears Genitourinary/Gynecological
Deferred Deferred
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:52 GMT -05:00
https://www.coursehero.com/file/235913183/NSG6430-Week-8-SOAP-Costa-Cdocx/
Student Name: Course: NSG6430
Name: K.P. Date: 04/02/24 Time: 1130
Ethnicity: White Age: 51 Sex: F
SUBJECTIVE
CC: “I have a couple of painless lumps on my right breast.”
HPI: A 51-year-old white female patient presents with a chief complaint of two painless
right-breast lumps that she detected four months ago. She denies any recent or past breast
trauma, breast discharge, bleeding, or overlying skin changes.
Medications: (list with reason for med )
Metoprolol 25mg twice a day
Furosemide 20mg daily 3 times a week
Metformin 500mg twice a day
PMH
Allergies: Penicillin- rash
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, type 2 diabetes, CHF
Hospitalizations/Surgeries- 3 cesareans, hysterectomy
Family History
M: Alive- 80 years old- Hypertension, hyperlipidemia, stroke
F: Unknown
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:52 GMT -05:00
https://www.coursehero.com/file/235913183/NSG6430-Week-8-SOAP-Costa-Cdocx/
, Social History
The patient is a non-smoker and consumes alcohol occasionally, with a balanced diet and
regular moderate exercise routine. She lives with her husband and two adult children,
maintaining good social support and family relationships.
ROS
General Cardiovascular
Patient denies night sweats, fatigue or weakness Denies any chest pain or shortness of breath,
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies dyspnea or cough
Eyes Gastrointestinal
Deferred Deferred
Ears Genitourinary/Gynecological
Deferred Deferred
This study source was downloaded by 100000885309857 from CourseHero.com on 06-23-2024 18:03:52 GMT -05:00
https://www.coursehero.com/file/235913183/NSG6430-Week-8-SOAP-Costa-Cdocx/
