CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Margie Blackman Course: NSG6020
Name:
Patient C.B. Time: 0900
Name
(Initials
ONLY):
Date: 3/13/26 Sex: Male
Age: 69 Ethnicity: African American
SUBJECTIVE (must complete this section)
CC: Patient presented with persistent diarrhea following recent
antibiotic treatment. Stool testing with PCP confirmed
Clostridioides difficile Infection. The provider initiated
appropriate antibiotic therapy and provided education
regarding infection control and hydration. The patient was
instructed to return if symptoms worsen or fail to improve.
HPI: C.B. is a 69-year-old African American male who presents
with persistent watery diarrhea for approximately 6 days
following completion of a 10-day course of clindamycin
prescribed for a dental infection. The patient reports 6–8
loose, watery stools per day associated with abdominal
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
cramping and mild fatigue. He denies blood in the stool but
reports a foul odor to stools. He also reports decreased
appetite and mild nausea but denies vomiting. No recent
travel or sick contacts. Stool testing performed by PCP was
positive for Clostridioides difficile toxin. The patient was
started on oral vancomycin therapy. He reports mild
improvement but continues to experience worsening
diarrhea. Denies fever, severe abdominal pain, or signs of
dehydration.
Medications: Vancomycin 125 mg PO four times daily for 10 days (initiated for
CDI)
Lisinopril 10 mg PO daily
Atorvastatin 20 mg PO nightly
Aspirin 81 mg PO daily
Previous Medical Hypertension, Hyperlipidemia, Osteoarthritis, History of dental
History: infection treated with antibiotics.
Allergies: Penicillin – rash
Medication None reported
Intolerances:
Chronic Hypertension, Hyperlipidemia, Osteoarthritis
Illnesses/Major
Traumas:
Student Margie Blackman Course: NSG6020
Name:
Patient C.B. Time: 0900
Name
(Initials
ONLY):
Date: 3/13/26 Sex: Male
Age: 69 Ethnicity: African American
SUBJECTIVE (must complete this section)
CC: Patient presented with persistent diarrhea following recent
antibiotic treatment. Stool testing with PCP confirmed
Clostridioides difficile Infection. The provider initiated
appropriate antibiotic therapy and provided education
regarding infection control and hydration. The patient was
instructed to return if symptoms worsen or fail to improve.
HPI: C.B. is a 69-year-old African American male who presents
with persistent watery diarrhea for approximately 6 days
following completion of a 10-day course of clindamycin
prescribed for a dental infection. The patient reports 6–8
loose, watery stools per day associated with abdominal
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
cramping and mild fatigue. He denies blood in the stool but
reports a foul odor to stools. He also reports decreased
appetite and mild nausea but denies vomiting. No recent
travel or sick contacts. Stool testing performed by PCP was
positive for Clostridioides difficile toxin. The patient was
started on oral vancomycin therapy. He reports mild
improvement but continues to experience worsening
diarrhea. Denies fever, severe abdominal pain, or signs of
dehydration.
Medications: Vancomycin 125 mg PO four times daily for 10 days (initiated for
CDI)
Lisinopril 10 mg PO daily
Atorvastatin 20 mg PO nightly
Aspirin 81 mg PO daily
Previous Medical Hypertension, Hyperlipidemia, Osteoarthritis, History of dental
History: infection treated with antibiotics.
Allergies: Penicillin – rash
Medication None reported
Intolerances:
Chronic Hypertension, Hyperlipidemia, Osteoarthritis
Illnesses/Major
Traumas:
