Course # NSG 6665
Complete SOAP Note
Subjective Data:
● Chief complaint (CC): “I am here for a physical examination.”
● HPI: 49 year old African-American female presented to the clinic requesting a physical
examinat
...
Course # NSG 6665
Complete SOAP Note
Subjective Data:
● Chief complaint (CC): “I am here for a physical examination.”
● HPI: 49 year old African-American female presented to the clinic requesting a physical
examination.
● PMH: Adult Illnesses: HTN, High Cholesterol. Hospitalization 1987 (Natural Childbirth)
Childhood Illnesses: Mumps, Chickenpox
● PSH: Natural Childbirth (1980) C-Section (1992) Bunionectomy (1999)
● Current Health Status:
1. Allergies: Denies
2. Tobacco use: Denies
3. Alcohol use: glass of Red wine socially twice month
4. Illicit Drug: Denies
5. Current medications:
a. Zocor 20mg PO at bedtime for high cholesterol
b. Hydrochlorothiazide 12.5 PO daily for HTN
c. Advil 200mg 2 tabs PO BID prn pain
6. Injuries: Denies
7. Environmental hazards: Patient denies exposure to environmental hazards at home or
work. She states she lives in a single dwelling home with her adult sister and brother.
No loose rugs or obstructing furniture. No stairs to enter home or within home. No
small pets
8. Screening tests: Eye exam 2016, 20/20 bilaterally with contacts, dental exam
11/2016, hearing exam normal results 2016. last Mammogram 2014.
9. Safety measures: confirms use of seat belts while riding in vehicles; wears helmet
when riding bike.
10. Immunizations: Flu shot- 8/3/2016. Does not take pneumonia vaccine. States
immunizations up to date. HBV, MMR, Varicello 10/2016.
11. Exercise and leisure:
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