CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient D.I Time: 07:17 pm
Name
(Initials
ONLY):
Date: 02/18/2026 Sex: male
Age: 71 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have been feeling very tired and experiencing shortness of
breath recently, on top of my usual back and leg pain.”
HPI: The patient is a 71-year-old male who presents with complaints of
progressive fatigue, generalized weakness, and shortness of breath
primarily during exertion, such as walking short distances or
climbing stairs. This shortness of breath improves with rest. He has
also experienced occasional palpitations over the past 3 months.
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
The patient reports that his fatigue is persistent and has gradually
worsened, limiting his ability to perform his usual daily activities.
He denies experiencing chest pain, syncope, or recent weight loss.
Additionally, he reports chronic lower back pain that radiates to the
right leg accompanied by numbness, for which he uses OTC
Ibuprofen.
Medications: - Lisinopril 20 mg PO once daily for hypertension
- Metformin 1000 mg two times daily for diabetes
- OTC Ibuprofen PRN for back pain
Previous Medical - COVID-19 (2021)
History:
- Left knee replacement (2017)
- Right knee replacement (2011)
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Illnesses/Major - Type 2 Diabetes Mellitus
Traumas:
- Chronic Kidney Disease (Stage 3)
- Peptic ulcer disease (2018)
Hospitalizations/ The patient is visiting his primary care provider once a year, except
Surgeries:
when experiencing exacerbations of chronic disease or flu
symptoms. He has undergone surgeries in the past:
- Left knee replacement (2017)
- Right knee replacement (2011)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 91 from heart attack
History of heart disease
MGM History of hypertension
(Maternal
Grandmother):
MGF (Maternal History of hypertension, diabetes
Grandfather):
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient D.I Time: 07:17 pm
Name
(Initials
ONLY):
Date: 02/18/2026 Sex: male
Age: 71 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I have been feeling very tired and experiencing shortness of
breath recently, on top of my usual back and leg pain.”
HPI: The patient is a 71-year-old male who presents with complaints of
progressive fatigue, generalized weakness, and shortness of breath
primarily during exertion, such as walking short distances or
climbing stairs. This shortness of breath improves with rest. He has
also experienced occasional palpitations over the past 3 months.
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
The patient reports that his fatigue is persistent and has gradually
worsened, limiting his ability to perform his usual daily activities.
He denies experiencing chest pain, syncope, or recent weight loss.
Additionally, he reports chronic lower back pain that radiates to the
right leg accompanied by numbness, for which he uses OTC
Ibuprofen.
Medications: - Lisinopril 20 mg PO once daily for hypertension
- Metformin 1000 mg two times daily for diabetes
- OTC Ibuprofen PRN for back pain
Previous Medical - COVID-19 (2021)
History:
- Left knee replacement (2017)
- Right knee replacement (2011)
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Illnesses/Major - Type 2 Diabetes Mellitus
Traumas:
- Chronic Kidney Disease (Stage 3)
- Peptic ulcer disease (2018)
Hospitalizations/ The patient is visiting his primary care provider once a year, except
Surgeries:
when experiencing exacerbations of chronic disease or flu
symptoms. He has undergone surgeries in the past:
- Left knee replacement (2017)
- Right knee replacement (2011)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 91 from heart attack
History of heart disease
MGM History of hypertension
(Maternal
Grandmother):
MGF (Maternal History of hypertension, diabetes
Grandfather):
