SOAP Note Week 2 Name: Amanda Bright________
Typhon Encounter #: _____________________
NU__610_:_________ Comprehensive:____Focused:____
Herzing University
S: SUBJECTIVE DATA
CC: Yearly Physical
HPI: This is a 51-year-old White male presenting for his annual physical
examination. Overall, he reports good health. His medical history is
significant for generalized anxiety, for which he sees a therapist, and well-
controlled hypertension managed with lisinopril. He monitors his blood
pressure twice daily and provided a log demonstrating readings
consistently within the normal range. He is currently asymptomatic and in
good health.
PMH: The patient was diagnosed with hypertension at age 31, which is currently
well controlled. As a child, the patient was hospitalized for burn injuries
but has no ongoing symptoms. Anxiety was first experienced at age 16,
for which the patient has been in therapy since; the condition is now well
managed. The patient has no history of surgical procedures.
ALLERGIES No known allergies
MEDICATIONS Lisinopril 40 mg-1 tablet once a day
Tylenol 325mg – 2 tablets every 6 hrs. as needed for pain/ fever
Ibuprofen 200mg- 2 tablets every 8 hrs. as needed for pain/ fever
SH Social History:
Education/Occupation: Pt is a high school graduate; works as a
master mechanic and owns/operates his own automotive shop.
Tobacco: Pt smokes ~½ ppd x 15 yrs.
Alcohol: Pt denies use.
Illicit Drugs: Pt denies use.
Caffeine: Pt drinks Mountain Dew; recently switched to zero-
sugar option to reduce caffeine intake.
Marital/Relationship: Pt not married; in long-term relationship x10
yrs with partner currently in NP school.
Stressors: Pt reports stress balancing FT job, business ownership,
and supporting partner in school.
Cultural/Religious: Pt acknowledges cultural beliefs, but none are
impacting medical decision-making.
Socioeconomic: Middle class; occasional financial strain reported.
Leisure: Pt enjoys fishing with family.
Living Situation: Pt resides in a single-family ranch home on 5
acres.
Exercise: Pt reports limited structured exercise due to work
demands; active during work hours and while managing ranch.
Nutrition: Diet includes processed foods and caffeinated
, SOAP Note Week 2 Name: Amanda Bright________
Typhon Encounter #: _____________________
NU__610_:_________ Comprehensive:____Focused:____
Herzing University
beverages; working on reducing soda intake.
Safety Habits: Pt reports consistent seatbelt use, follows safety
precautions at work (protective equipment), and maintains smoke
detectors at home.
Sexual History:
Pt in monogamous relationship x10 yrs.
Both partners complete routine STI screening during annual
exams.
Pt denies hx of STIs.
Pt denies concerns with sexual function.
FH Family History:
Paternal Side:
o Father: Deceased; hypertension, coronary artery disease,
seizure disorder.
o Paternal grandparents: Both deceased; grandfather had type
2 diabetes, grandmother had osteoarthritis.
Maternal Side:
o Mother: Deceased; breast cancer, hyperlipidemia, seizure
disorder.
o Maternal grandparents: Both deceased; grandfather had
myocardial infarction, grandmother had osteoporosis.
Siblings:
o Two brothers: Deceased; heart-related conditions, one had
seizure disorder, both had histories of alcohol use and
substance abuse.
o One sister: Living; diabetes, heart disease; occasional
alcohol use, no substance abuse.
Children:
o Three adult biological children with ex-wife: generally
healthy; no significant chronic illnesses reported.
o Two stepchildren from current marriage: generally healthy.
o One biological son with current spouse: generally healthy.
HEALTH Required for all SOAP notes:
PROMOTION & Vaccinations (CDC Recommended):
MAINTENANC COVID-19: Educated on risk and benefits patient refused
E Influenza: Educated on risk and benefits patient refused
Tdap: last received 04-24-20
MMR: immune per titers 04-24-20
Varicella: immune per titers 04-24-20
HPV: Consider 27–45y Educated on risk and benefits, patient
Typhon Encounter #: _____________________
NU__610_:_________ Comprehensive:____Focused:____
Herzing University
S: SUBJECTIVE DATA
CC: Yearly Physical
HPI: This is a 51-year-old White male presenting for his annual physical
examination. Overall, he reports good health. His medical history is
significant for generalized anxiety, for which he sees a therapist, and well-
controlled hypertension managed with lisinopril. He monitors his blood
pressure twice daily and provided a log demonstrating readings
consistently within the normal range. He is currently asymptomatic and in
good health.
PMH: The patient was diagnosed with hypertension at age 31, which is currently
well controlled. As a child, the patient was hospitalized for burn injuries
but has no ongoing symptoms. Anxiety was first experienced at age 16,
for which the patient has been in therapy since; the condition is now well
managed. The patient has no history of surgical procedures.
ALLERGIES No known allergies
MEDICATIONS Lisinopril 40 mg-1 tablet once a day
Tylenol 325mg – 2 tablets every 6 hrs. as needed for pain/ fever
Ibuprofen 200mg- 2 tablets every 8 hrs. as needed for pain/ fever
SH Social History:
Education/Occupation: Pt is a high school graduate; works as a
master mechanic and owns/operates his own automotive shop.
Tobacco: Pt smokes ~½ ppd x 15 yrs.
Alcohol: Pt denies use.
Illicit Drugs: Pt denies use.
Caffeine: Pt drinks Mountain Dew; recently switched to zero-
sugar option to reduce caffeine intake.
Marital/Relationship: Pt not married; in long-term relationship x10
yrs with partner currently in NP school.
Stressors: Pt reports stress balancing FT job, business ownership,
and supporting partner in school.
Cultural/Religious: Pt acknowledges cultural beliefs, but none are
impacting medical decision-making.
Socioeconomic: Middle class; occasional financial strain reported.
Leisure: Pt enjoys fishing with family.
Living Situation: Pt resides in a single-family ranch home on 5
acres.
Exercise: Pt reports limited structured exercise due to work
demands; active during work hours and while managing ranch.
Nutrition: Diet includes processed foods and caffeinated
, SOAP Note Week 2 Name: Amanda Bright________
Typhon Encounter #: _____________________
NU__610_:_________ Comprehensive:____Focused:____
Herzing University
beverages; working on reducing soda intake.
Safety Habits: Pt reports consistent seatbelt use, follows safety
precautions at work (protective equipment), and maintains smoke
detectors at home.
Sexual History:
Pt in monogamous relationship x10 yrs.
Both partners complete routine STI screening during annual
exams.
Pt denies hx of STIs.
Pt denies concerns with sexual function.
FH Family History:
Paternal Side:
o Father: Deceased; hypertension, coronary artery disease,
seizure disorder.
o Paternal grandparents: Both deceased; grandfather had type
2 diabetes, grandmother had osteoarthritis.
Maternal Side:
o Mother: Deceased; breast cancer, hyperlipidemia, seizure
disorder.
o Maternal grandparents: Both deceased; grandfather had
myocardial infarction, grandmother had osteoporosis.
Siblings:
o Two brothers: Deceased; heart-related conditions, one had
seizure disorder, both had histories of alcohol use and
substance abuse.
o One sister: Living; diabetes, heart disease; occasional
alcohol use, no substance abuse.
Children:
o Three adult biological children with ex-wife: generally
healthy; no significant chronic illnesses reported.
o Two stepchildren from current marriage: generally healthy.
o One biological son with current spouse: generally healthy.
HEALTH Required for all SOAP notes:
PROMOTION & Vaccinations (CDC Recommended):
MAINTENANC COVID-19: Educated on risk and benefits patient refused
E Influenza: Educated on risk and benefits patient refused
Tdap: last received 04-24-20
MMR: immune per titers 04-24-20
Varicella: immune per titers 04-24-20
HPV: Consider 27–45y Educated on risk and benefits, patient
