COMPREHENSIVE SOAP
***
NUR 7011-812
Prof. ***
December 10th, 2025
Log ID: 251211023707
, 2
SUBJECTIVE
CC: “My stomach has hurt for the past 3 days.”
HPI: 43-year-old male who presents today with left upper quadrant (LUQ) abdominal
pain for the past three days, accompanied by acid reflux and dry mouth. Symptoms began
gradually over the last month. The pain is localized to the LUQ and described as a
constant discomfort with intermittent sharp, reflux-like episodes rated 5/10, with no
radiation. The pain is persistent throughout the day. Patient unsure if it’s related to diet,
he reports eating spicy foods, and he drinks approximately three cups of coffee daily. He
reports that lying down shortly after eating consistently worsens the burning and
discomfort. Has not found any that relieve symptoms. He has not taken any over-the-
counter medications, including antacids or acetaminophen. He reports no nausea,
vomiting, diarrhea, constipation, loss of appetite, fever, halitosis, or other systemic
symptoms. He reports recent travel to the Dominican Republic in July and states that his
wife tested positive for H. pylori last week.
PMH: Hyperlipidemia and prediabetes. The patient has not had any recent
hospitalizations or blood transfusions.
PSH: None.
Medications: The patient is not taking any medications, vitamins, or supplements at this
time.
, 3
Health Maintenance:
Immunizations:
COVID vaccine: 5/15/2021 & 6/4/2021
Influenza vaccine: Due; patient declined
Pneumovax 23, Prevnar 13, Prevnar 20: Not applicable
RSV vaccine: Not applicable
Shingles vaccine: Not applicable
Tetanus, diphtheria, and pertussis vaccine (Tdap) vaccine: 5/14/2025
Colonoscopy: N/A
Cologuard within 3 years: N/A
Eye Exam: Completed on 2/2025
Dental Exam: Completed on 4/2025
POLST: N/A
Family History: No known family history of medical conditions. The patient specifically
denies any family history of colon cancer.
Social History: The patient lives with his domestic partner, their two children, and no
pets in a stable home environment with good family support. Smoke and carbon
monoxide detectors are present in home. Denies guns at home. He has an associate's
degree and works full-time as a plumber, a job that involves frequent physical labor,
including bending and lifting, as well as irregular meal patterns. He reports using
appropriate safety measures at work. Denies any financial strain or difficulty accessing
healthcare or medications. He follows a regular diet that includes spicy foods, drinks
***
NUR 7011-812
Prof. ***
December 10th, 2025
Log ID: 251211023707
, 2
SUBJECTIVE
CC: “My stomach has hurt for the past 3 days.”
HPI: 43-year-old male who presents today with left upper quadrant (LUQ) abdominal
pain for the past three days, accompanied by acid reflux and dry mouth. Symptoms began
gradually over the last month. The pain is localized to the LUQ and described as a
constant discomfort with intermittent sharp, reflux-like episodes rated 5/10, with no
radiation. The pain is persistent throughout the day. Patient unsure if it’s related to diet,
he reports eating spicy foods, and he drinks approximately three cups of coffee daily. He
reports that lying down shortly after eating consistently worsens the burning and
discomfort. Has not found any that relieve symptoms. He has not taken any over-the-
counter medications, including antacids or acetaminophen. He reports no nausea,
vomiting, diarrhea, constipation, loss of appetite, fever, halitosis, or other systemic
symptoms. He reports recent travel to the Dominican Republic in July and states that his
wife tested positive for H. pylori last week.
PMH: Hyperlipidemia and prediabetes. The patient has not had any recent
hospitalizations or blood transfusions.
PSH: None.
Medications: The patient is not taking any medications, vitamins, or supplements at this
time.
, 3
Health Maintenance:
Immunizations:
COVID vaccine: 5/15/2021 & 6/4/2021
Influenza vaccine: Due; patient declined
Pneumovax 23, Prevnar 13, Prevnar 20: Not applicable
RSV vaccine: Not applicable
Shingles vaccine: Not applicable
Tetanus, diphtheria, and pertussis vaccine (Tdap) vaccine: 5/14/2025
Colonoscopy: N/A
Cologuard within 3 years: N/A
Eye Exam: Completed on 2/2025
Dental Exam: Completed on 4/2025
POLST: N/A
Family History: No known family history of medical conditions. The patient specifically
denies any family history of colon cancer.
Social History: The patient lives with his domestic partner, their two children, and no
pets in a stable home environment with good family support. Smoke and carbon
monoxide detectors are present in home. Denies guns at home. He has an associate's
degree and works full-time as a plumber, a job that involves frequent physical labor,
including bending and lifting, as well as irregular meal patterns. He reports using
appropriate safety measures at work. Denies any financial strain or difficulty accessing
healthcare or medications. He follows a regular diet that includes spicy foods, drinks
