S.O.A.P. Note Template CASE ID# Tina Jones
Abdomen Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
What brought you here
“I’ve been having stomach pain for a while.”
mplaint
today (eg. headache)
Chronological order of events, state of health before onset of CC, must include OLDCARTS in
paragraph form
Onset Patient is a 28-year-old African American woman who presented to the
Location clinic with complaints of upper stomach pain after eating. She reports the
Duration pain started about a month ago. She states that she experiences pain daily
Character
starting after meals usually lasting “a few hours.” She reports pain is a 5/10
Aggravating/associate
d factors in her upper stomach after eating. She reports pain is a 7/10 when lying
Relieving factors down. She describes the pain similar to heartburn. She notes it to increase
History
Present
Illness
Temporal factors – with consumption of food. She states pain is worse after fast food and spicy
of
other things going on food. She reports decreased appetite and not wanting to eat because of
anticipation of pain. She denies any recent changes to her diet besides an
increase in water intake. She denies coffee intake but does drink diet cola
daily. She states that the pain usually goes away several hours after eating
Severity but that she does treat the pain “every few days” with an over the counter
antacid with some relief. She reports burping after meals and denies any
recent weight loss. She denies any gastrointestinal history but does report
her grandfather passed away from colon cancer.
Adult Illnesses,
Medical
History
childhood illnesses, Adult illness: diabetes, asthma
Past
immunizations, Childhood illness: asthma at 2.5 years old
surgeries, allergies, Immunizations: up to date, received annual flu shot
Include Parents, Mother: Alive 59 y.o., High blood pressure, high cholesterol
History
Family
siblings; grandparents Father: Deceased at 58 due to car accident Type II Diabetes, high
if applicable/known, blood pressure, high cholesterol
cause of death, age, Paternal grandmother: Alive 84 y.o., High blood pressure, high cholesterol
Education, marital
Personal/Social
status, occupation, Education: Current Student
Marital Status: Single
History
alcohol/drug use,
Occupation: supervisor at Mid-American Copy and Ship
smoking status, sexual
Religion: Christian
history if relevant, Social History: Denies drug use, non-smoker, denies vaping,
exercise, nutrition, social drinking- no more than 4 drinks a month
This study source was downloaded by 100000852681095 from CourseHero.com on 12-08-2022 02:16:56 GMT -06:00
https://www.coursehero.com/file/66475733/Gastrointestinal-Tina-Jones-SOAPdocx/
Abdomen Subjective
Objective
Assessment (diagnosis [primary and differential diagnosis])
Plan (treatment, education, and follow up plan)
What brought you here
“I’ve been having stomach pain for a while.”
mplaint
today (eg. headache)
Chronological order of events, state of health before onset of CC, must include OLDCARTS in
paragraph form
Onset Patient is a 28-year-old African American woman who presented to the
Location clinic with complaints of upper stomach pain after eating. She reports the
Duration pain started about a month ago. She states that she experiences pain daily
Character
starting after meals usually lasting “a few hours.” She reports pain is a 5/10
Aggravating/associate
d factors in her upper stomach after eating. She reports pain is a 7/10 when lying
Relieving factors down. She describes the pain similar to heartburn. She notes it to increase
History
Present
Illness
Temporal factors – with consumption of food. She states pain is worse after fast food and spicy
of
other things going on food. She reports decreased appetite and not wanting to eat because of
anticipation of pain. She denies any recent changes to her diet besides an
increase in water intake. She denies coffee intake but does drink diet cola
daily. She states that the pain usually goes away several hours after eating
Severity but that she does treat the pain “every few days” with an over the counter
antacid with some relief. She reports burping after meals and denies any
recent weight loss. She denies any gastrointestinal history but does report
her grandfather passed away from colon cancer.
Adult Illnesses,
Medical
History
childhood illnesses, Adult illness: diabetes, asthma
Past
immunizations, Childhood illness: asthma at 2.5 years old
surgeries, allergies, Immunizations: up to date, received annual flu shot
Include Parents, Mother: Alive 59 y.o., High blood pressure, high cholesterol
History
Family
siblings; grandparents Father: Deceased at 58 due to car accident Type II Diabetes, high
if applicable/known, blood pressure, high cholesterol
cause of death, age, Paternal grandmother: Alive 84 y.o., High blood pressure, high cholesterol
Education, marital
Personal/Social
status, occupation, Education: Current Student
Marital Status: Single
History
alcohol/drug use,
Occupation: supervisor at Mid-American Copy and Ship
smoking status, sexual
Religion: Christian
history if relevant, Social History: Denies drug use, non-smoker, denies vaping,
exercise, nutrition, social drinking- no more than 4 drinks a month
This study source was downloaded by 100000852681095 from CourseHero.com on 12-08-2022 02:16:56 GMT -06:00
https://www.coursehero.com/file/66475733/Gastrointestinal-Tina-Jones-SOAPdocx/
