CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6020_A-Advanced
Name: Health &Physical
Assessment
Patient A.O. Time: 30
Name
(Initials
ONLY):
Date: 11/24/2025 Sex: male
Age: 67 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have had a gnawing, aching pain in my legs for the past 3
months. Skin on my calves turning purple.”
HPI: A.O. is a 67 years old artist with a known history of chronic
venous insufficiency with varicose veins who comes to the office
with complaints of worsening skin discoloration of both lower legs
and new onset muscle gnawing pain in his legs for the past 3
months. He describes a pain as a deep, gnawing muscle soreness,
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
accompanied by regular sensations of heaviness and cramping in
the legs, usually worse with long standing. That is related to his
activity, and he noticed it is partially relieved with leg
repositioning and elevating. He states that the muscle pain started
shortly after he started using a new drug for high cholesterol.
Additionally, he noticed that veins on both legs have become more
visible, and the skin around his ankles has darkened over the past
year, having become purple and more noticeable. The patient
denies trauma, difficulty walking, leg numbness, ulcers or
drainage, chest pain, and shortness of breath. He does not wear
compression stockings.
Medications: Lisinopril 10 mg PO once daily
Duration: chronic administration for hypertension.
SE: dry cough, dizziness, hypotension.
Teaching: report any swelling of the face, lips, or tongue;
do not stop abruptly.
Aspirin 81 mg PO once daily
Duration: chronic administration for cardiovascular
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
protection.
SE: GI upset, increased bleeding risk, and bruising.
Teaching: Take with food to reduce stomach upset, inform
provider about black stool, easy bruising.
Atorvastatin 30 mg PO once daily in the evening
Duration: chronic administration for hyperlipidemia.
SE: GI upset, muscle pain, headache.
Teaching: Take at the same time each day, inform
provider any new onset muscle pain, avoid
grapefruit juice.
Febuxostat 40 mg PO once daily
Duration: chronic administration for gout control.
SE: nausea, joint pain, skin rash.
Teaching: take medication daily, even in the absence of
symptoms. Ensure proper hydration and inform
provider if experiencing severe stomach pain,
yellowing of the eyes and skin, or dark urine.
Omeprazole 20 mg PO once daily
Student Course: NSG6020_A-Advanced
Name: Health &Physical
Assessment
Patient A.O. Time: 30
Name
(Initials
ONLY):
Date: 11/24/2025 Sex: male
Age: 67 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have had a gnawing, aching pain in my legs for the past 3
months. Skin on my calves turning purple.”
HPI: A.O. is a 67 years old artist with a known history of chronic
venous insufficiency with varicose veins who comes to the office
with complaints of worsening skin discoloration of both lower legs
and new onset muscle gnawing pain in his legs for the past 3
months. He describes a pain as a deep, gnawing muscle soreness,
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
accompanied by regular sensations of heaviness and cramping in
the legs, usually worse with long standing. That is related to his
activity, and he noticed it is partially relieved with leg
repositioning and elevating. He states that the muscle pain started
shortly after he started using a new drug for high cholesterol.
Additionally, he noticed that veins on both legs have become more
visible, and the skin around his ankles has darkened over the past
year, having become purple and more noticeable. The patient
denies trauma, difficulty walking, leg numbness, ulcers or
drainage, chest pain, and shortness of breath. He does not wear
compression stockings.
Medications: Lisinopril 10 mg PO once daily
Duration: chronic administration for hypertension.
SE: dry cough, dizziness, hypotension.
Teaching: report any swelling of the face, lips, or tongue;
do not stop abruptly.
Aspirin 81 mg PO once daily
Duration: chronic administration for cardiovascular
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
protection.
SE: GI upset, increased bleeding risk, and bruising.
Teaching: Take with food to reduce stomach upset, inform
provider about black stool, easy bruising.
Atorvastatin 30 mg PO once daily in the evening
Duration: chronic administration for hyperlipidemia.
SE: GI upset, muscle pain, headache.
Teaching: Take at the same time each day, inform
provider any new onset muscle pain, avoid
grapefruit juice.
Febuxostat 40 mg PO once daily
Duration: chronic administration for gout control.
SE: nausea, joint pain, skin rash.
Teaching: take medication daily, even in the absence of
symptoms. Ensure proper hydration and inform
provider if experiencing severe stomach pain,
yellowing of the eyes and skin, or dark urine.
Omeprazole 20 mg PO once daily
