CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient A.M. Time: 05:15 pm
Name
(Initials
ONLY):
Date: 03/03/26 Sex: male
Age: 67 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have to go to the bathroom very often during the day and night,
and it disturbs my rest. Also, I feel the urge to urinate again just
five minutes after using the bathroom, and the flow of my urine is
very slow.”
HPI: A.M. is a 67-year-old male presenting with a one-month history of
gradually worsening lower urinary tract symptoms. The patient
reports increased urinary frequency, nocturia occurring two to
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
three times per night, difficulty initiating urination, a weak urinary
stream, and a sensation of incomplete bladder emptying. These
symptoms have been persistent, occurring daily both during the
day and at night. He has not identified any specific aggravating
factors and has not attempted any medications or interventions to
alleviate the symptoms. The nocturia has been disrupting his sleep.
The patient denies experiencing hematuria, penile discharge,
erectile dysfunction, fever, chills, flank pain, nausea, or vomiting.
He reports having unprotected sexual intercourse with a new
partner two weeks prior to the onset of symptoms. His past medical
history is unremarkable for urologic conditions, prior prostate
issues, recent urologic procedures, or kidney stones.
Medications: - Amlodipine 10 mg PO once daily for hypertension
- Zolpidem 5 mg PO before bedtime for sleep as needed
Previous Medical - COVID-19 (2020)
History:
- Pneumonia (2020)
Allergies: NKA
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Insomnia
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider two times a year, except when experiencing exacerbations
of chronic disease or flu symptoms. He has undergone surgeries in
the past:
- Appendectomy (1978)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 87 from CHF
History of diabetes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient A.M. Time: 05:15 pm
Name
(Initials
ONLY):
Date: 03/03/26 Sex: male
Age: 67 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have to go to the bathroom very often during the day and night,
and it disturbs my rest. Also, I feel the urge to urinate again just
five minutes after using the bathroom, and the flow of my urine is
very slow.”
HPI: A.M. is a 67-year-old male presenting with a one-month history of
gradually worsening lower urinary tract symptoms. The patient
reports increased urinary frequency, nocturia occurring two to
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
three times per night, difficulty initiating urination, a weak urinary
stream, and a sensation of incomplete bladder emptying. These
symptoms have been persistent, occurring daily both during the
day and at night. He has not identified any specific aggravating
factors and has not attempted any medications or interventions to
alleviate the symptoms. The nocturia has been disrupting his sleep.
The patient denies experiencing hematuria, penile discharge,
erectile dysfunction, fever, chills, flank pain, nausea, or vomiting.
He reports having unprotected sexual intercourse with a new
partner two weeks prior to the onset of symptoms. His past medical
history is unremarkable for urologic conditions, prior prostate
issues, recent urologic procedures, or kidney stones.
Medications: - Amlodipine 10 mg PO once daily for hypertension
- Zolpidem 5 mg PO before bedtime for sleep as needed
Previous Medical - COVID-19 (2020)
History:
- Pneumonia (2020)
Allergies: NKA
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Insomnia
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider two times a year, except when experiencing exacerbations
of chronic disease or flu symptoms. He has undergone surgeries in
the past:
- Appendectomy (1978)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 87 from CHF
History of diabetes
