1
SOAP note 2
Sydney Collins, BSN, RN
College of Nursing and Health Innovation, University of Texas Arlington
NURS 5337-450
Dr. Doris Harvey, FNP-C
April 2, 2025
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, 2
SOAP Note CP1 #1
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
D.C, 25 year old male, good historian
Insurance: Blue cross blue shield of Texas-PPO -father (68 yr): A&W
-mother: (55 yr) hx of
breast cancer,
hypothyroid
-Sister (31 yr)
hypothyroid
-sister 29 yr)-bipolar
disorder
-son (1 yr)- A&W
Personal/Social Hx:
Chief Concern/RFE: -non smoker
“neck and lower back pain” -alcohol twice
monthly
-no illicit drug use
-Lives in home with
wife and 1 sons, in
sanitary conditions
-Occupation: Security
gaurd
-no environmental or
occupational
Hx Present Illness: exposures
D.C a 25 year old male with no past medical history reports to the clinic following a motor vehicle accident 2 days ago with
complaint of neck and lower back pain.
Onset
Location
Duration
Characteristics
Aggravating
Relieving
Treatment
Severity
CURRENT HEALTH
Medications: Olmesartan 40m 1 tablet by mouth daily-MOA: Olmesartan is an angiotensin 2 receptor blocker (ARB). It binds
to angiotensin receptor 1 and prevents the protein angiotensin 2 from binding and exerting its hypertensive effects, which
include vasoconstriction, stimulation and synthesis of aldosterone and anti-diuretic hormone, cardiac stimulation, and renal
reabsorption of sodium (Arcangelo et al., 2022). Dose: Typical dose for hypertension is 20-40mg 1 tablet by mouth. Side
effects: Dizziness and hypotension are common, check blood pressures at home daily. May cause hyperkalemia-signs and
symptoms include muscle weakness, numbness and tingling, and chest pain or palpitations.
Allergies: No known drug or food allergies, seasonal allergies include cats, molds, oak and mountain cedar-reaction includes
itching nose and eyes, sneezing, and rhinorrhea
Last PE & Screenings: PE: 7/2024, eye exam: never, dental exam: 2 years, colonoscopy-at age 45
Immunization Status: childhood vaccines up to date, Tdap-2018, Influenza-did not receive, Covid-1 dose 12/2021, no
boosters
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SOAP note 2
Sydney Collins, BSN, RN
College of Nursing and Health Innovation, University of Texas Arlington
NURS 5337-450
Dr. Doris Harvey, FNP-C
April 2, 2025
This study source was downloaded by 100000900412927 from CourseHero.com on 10-29-2025 14:56:00 GMT -05:00
https://www.coursehero.com/file/250604845/Soap-note-1docx/
, 2
SOAP Note CP1 #1
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
D.C, 25 year old male, good historian
Insurance: Blue cross blue shield of Texas-PPO -father (68 yr): A&W
-mother: (55 yr) hx of
breast cancer,
hypothyroid
-Sister (31 yr)
hypothyroid
-sister 29 yr)-bipolar
disorder
-son (1 yr)- A&W
Personal/Social Hx:
Chief Concern/RFE: -non smoker
“neck and lower back pain” -alcohol twice
monthly
-no illicit drug use
-Lives in home with
wife and 1 sons, in
sanitary conditions
-Occupation: Security
gaurd
-no environmental or
occupational
Hx Present Illness: exposures
D.C a 25 year old male with no past medical history reports to the clinic following a motor vehicle accident 2 days ago with
complaint of neck and lower back pain.
Onset
Location
Duration
Characteristics
Aggravating
Relieving
Treatment
Severity
CURRENT HEALTH
Medications: Olmesartan 40m 1 tablet by mouth daily-MOA: Olmesartan is an angiotensin 2 receptor blocker (ARB). It binds
to angiotensin receptor 1 and prevents the protein angiotensin 2 from binding and exerting its hypertensive effects, which
include vasoconstriction, stimulation and synthesis of aldosterone and anti-diuretic hormone, cardiac stimulation, and renal
reabsorption of sodium (Arcangelo et al., 2022). Dose: Typical dose for hypertension is 20-40mg 1 tablet by mouth. Side
effects: Dizziness and hypotension are common, check blood pressures at home daily. May cause hyperkalemia-signs and
symptoms include muscle weakness, numbness and tingling, and chest pain or palpitations.
Allergies: No known drug or food allergies, seasonal allergies include cats, molds, oak and mountain cedar-reaction includes
itching nose and eyes, sneezing, and rhinorrhea
Last PE & Screenings: PE: 7/2024, eye exam: never, dental exam: 2 years, colonoscopy-at age 45
Immunization Status: childhood vaccines up to date, Tdap-2018, Influenza-did not receive, Covid-1 dose 12/2021, no
boosters
This study source was downloaded by 100000900412927 from CourseHero.com on 10-29-2025 14:56:00 GMT -05:00
https://www.coursehero.com/file/250604845/Soap-note-1docx/
