CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient E. B. Time: 09:51 pm
Name
(Initials
ONLY):
Date: 02/26/2026 Sex: female
Age: 69 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have a persistent throbbing headache for the past 4 days.”
HPI: The patient is a 69-year-old female presenting with a new-onset
headache that has lasted for 4 days. The symptoms began gradually
after experiencing a viral upper respiratory infection approximately
10 days ago, with low-grade fever, congestion, and fatigue, which
resolved without complications. The pain is primarily located in
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
the right frontal-temporal region and is mostly characterized as
"pulsating" or throbbing and rated 8/10 in severity. The headache
episodes are persistent throughout the day, varying in intensity and
accompanied by nausea and sensitivity to light. Aggravating
factors include light, loud noises, and routine physical activity,
which the patient reports "makes my head pound harder."
Relieving factors consist of resting in a dark, quiet room and
applying a cool compress to her forehead. She has attempted to
alleviate the pain with over-the-counter acetaminophen 500 mg but
has experienced minimal relief. Additionally, the patient reports
experiencing occasional shooting pain in her right temple and jaw,
particularly after eating. This pain began around the same time as
her upper viral infection and a few days after she completed her
dental work. The patient denies any recent trauma, falls, or head
injuries. She also reports no fever, neck stiffness, or sudden
changes in vision.
Medications: - Lisinopril 20 mg PO once daily for hypertension
- Zolpidem 5 mg PO before bedtime PRN for sleep
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
- OTC Acetaminophen 500 mg PRN for pain
Previous Medical - COVID-19 (2020, 2022, 2023)
History:
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Insomnia
- Obesity
Hospitalizations/ The patient is visiting his primary care provider three times a year,
Surgeries:
except when experiencing exacerbations of chronic disease or flu
symptoms. He has undergone surgeries in the past:
- Ectopic pregnancy (1989)
- Hysterectomy (1993)
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient E. B. Time: 09:51 pm
Name
(Initials
ONLY):
Date: 02/26/2026 Sex: female
Age: 69 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have a persistent throbbing headache for the past 4 days.”
HPI: The patient is a 69-year-old female presenting with a new-onset
headache that has lasted for 4 days. The symptoms began gradually
after experiencing a viral upper respiratory infection approximately
10 days ago, with low-grade fever, congestion, and fatigue, which
resolved without complications. The pain is primarily located in
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
the right frontal-temporal region and is mostly characterized as
"pulsating" or throbbing and rated 8/10 in severity. The headache
episodes are persistent throughout the day, varying in intensity and
accompanied by nausea and sensitivity to light. Aggravating
factors include light, loud noises, and routine physical activity,
which the patient reports "makes my head pound harder."
Relieving factors consist of resting in a dark, quiet room and
applying a cool compress to her forehead. She has attempted to
alleviate the pain with over-the-counter acetaminophen 500 mg but
has experienced minimal relief. Additionally, the patient reports
experiencing occasional shooting pain in her right temple and jaw,
particularly after eating. This pain began around the same time as
her upper viral infection and a few days after she completed her
dental work. The patient denies any recent trauma, falls, or head
injuries. She also reports no fever, neck stiffness, or sudden
changes in vision.
Medications: - Lisinopril 20 mg PO once daily for hypertension
- Zolpidem 5 mg PO before bedtime PRN for sleep
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
- OTC Acetaminophen 500 mg PRN for pain
Previous Medical - COVID-19 (2020, 2022, 2023)
History:
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Insomnia
- Obesity
Hospitalizations/ The patient is visiting his primary care provider three times a year,
Surgeries:
except when experiencing exacerbations of chronic disease or flu
symptoms. He has undergone surgeries in the past:
- Ectopic pregnancy (1989)
- Hysterectomy (1993)
