CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient T. B. Time: 07:58 pm
Name
(Initials
ONLY):
Date: 02/11/2026 Sex: female
Age: 60 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I experience a racing heart, excessive sweating, and restlessness. I
struggle to sleep well at night, which leaves me feeling very tired
during the day.”
HPI: T.B. is a 60-year-old woman who presents with complaints of a
racing heart, excessive sweating, restlessness, increased frequency
of bowel movements, and poor sleep. These symptoms began
approximately 2 to 3 months ago and have gradually worsened
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
over time. She experiences a racing heart daily, both at rest and
during activity, describing the sensation as fast and pounding.
Additional symptoms include fatigue and heat intolerance. She
denies experiencing chest pain, syncope, or any recent illness.
Warm environments and stress tend to exacerbate her symptoms,
while rest provides slight relief. T.B. has no prior history of similar
symptoms and reports no recent changes in medication.
Medications: - Amlodipine 10 mg PO once daily for hypertension
- Metformin 500 mg once daily for diabetes
Previous Medical - COVID-19 (2021, 2024)
History:
- Cholecystectomy (2018)
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas:
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
- Type 2 Diabetes Mellitus
- Obesity
Hospitalizations/ The patient receives regular medical care, visiting her primary care
Surgeries:
provider three times a year, except when experiencing
exacerbations of chronic disease or flu symptoms. She has
undergone surgeries in the past:
- Cholecystectomy (2018)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 82 from heart attack
History of diabetes, heart disease
MGM History of hypertension
(Maternal
Grandmother):
MGF (Maternal History of hypertension, glaucoma, diabetes
Grandfather):
F (Father): Father is deceased at 80 from sepsis
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient T. B. Time: 07:58 pm
Name
(Initials
ONLY):
Date: 02/11/2026 Sex: female
Age: 60 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I experience a racing heart, excessive sweating, and restlessness. I
struggle to sleep well at night, which leaves me feeling very tired
during the day.”
HPI: T.B. is a 60-year-old woman who presents with complaints of a
racing heart, excessive sweating, restlessness, increased frequency
of bowel movements, and poor sleep. These symptoms began
approximately 2 to 3 months ago and have gradually worsened
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
over time. She experiences a racing heart daily, both at rest and
during activity, describing the sensation as fast and pounding.
Additional symptoms include fatigue and heat intolerance. She
denies experiencing chest pain, syncope, or any recent illness.
Warm environments and stress tend to exacerbate her symptoms,
while rest provides slight relief. T.B. has no prior history of similar
symptoms and reports no recent changes in medication.
Medications: - Amlodipine 10 mg PO once daily for hypertension
- Metformin 500 mg once daily for diabetes
Previous Medical - COVID-19 (2021, 2024)
History:
- Cholecystectomy (2018)
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas:
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
- Type 2 Diabetes Mellitus
- Obesity
Hospitalizations/ The patient receives regular medical care, visiting her primary care
Surgeries:
provider three times a year, except when experiencing
exacerbations of chronic disease or flu symptoms. She has
undergone surgeries in the past:
- Cholecystectomy (2018)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 82 from heart attack
History of diabetes, heart disease
MGM History of hypertension
(Maternal
Grandmother):
MGF (Maternal History of hypertension, glaucoma, diabetes
Grandfather):
F (Father): Father is deceased at 80 from sepsis
