CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient O.B. Time: 06:32 pm
Name
(Initials
ONLY):
Date: 01/21/2026 Sex: female
Age: 71 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I had the flu three weeks ago and got better after about 10 days,
but for the last seven days, I’ve been getting short of breath when I
do housework or take care of my sick husband. During the day and
a few times at night, I also cough a little. Most of the time, it's dry
with some white sputum. And I noticed that my legs got bigger,
which made my shoes not fit well.”
HPI: O.B., a 71-year-old woman, reports experiencing shortness of
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
breath for the past seven days following the flu. This symptom is
particularly noticeable during exertion, such as performing
household chores and caring for her chronically ill husband.
Dyspnea gradually improves when she ceases activity. She also
reports a mostly dry cough with occasional production of a small
amount of white sputum, occurring sporadically during the day and
occasionally at night. Additionally, she has noticed a new onset of
swelling in her legs, making it difficult for her to wear her shoes.
She experienced influenza three weeks ago, from which she
recovered in about 10 days with symptomatic treatment. She denies
having fever, chest pain, orthopnea, paroxysmal nocturnal dyspnea,
or hemoptysis. O.B. has a history of asthma but has not used any
medications for approximately four years.
Medications: Amlodipine 10 mg PO once daily for hypertension
Lisinopril 10 mg PO once daily for hypertension
Previous Medical - Breast cancer, left mastectomy (1991)
History:
Allergies: Allergic to cats (sneezing, nose congestion, coughing)
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Chronic hypertension
Illnesses/Major
Traumas: - Asthma
Hospitalizations/ The patient receives regular medical care, visiting her oncologist
Surgeries:
and her primary care provider three times a year, except when
experiencing exacerbations of chronic disease or flu symptoms.
She has undergone surgeries in the past:
- Breast cancer, left mastectomy (1991)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 71 from CKD
History of HF, CKD, gout
MGM History of gout
(Maternal
Grandmother):
MGF (Maternal History of hypertension
Grandfather):
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient O.B. Time: 06:32 pm
Name
(Initials
ONLY):
Date: 01/21/2026 Sex: female
Age: 71 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I had the flu three weeks ago and got better after about 10 days,
but for the last seven days, I’ve been getting short of breath when I
do housework or take care of my sick husband. During the day and
a few times at night, I also cough a little. Most of the time, it's dry
with some white sputum. And I noticed that my legs got bigger,
which made my shoes not fit well.”
HPI: O.B., a 71-year-old woman, reports experiencing shortness of
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
breath for the past seven days following the flu. This symptom is
particularly noticeable during exertion, such as performing
household chores and caring for her chronically ill husband.
Dyspnea gradually improves when she ceases activity. She also
reports a mostly dry cough with occasional production of a small
amount of white sputum, occurring sporadically during the day and
occasionally at night. Additionally, she has noticed a new onset of
swelling in her legs, making it difficult for her to wear her shoes.
She experienced influenza three weeks ago, from which she
recovered in about 10 days with symptomatic treatment. She denies
having fever, chest pain, orthopnea, paroxysmal nocturnal dyspnea,
or hemoptysis. O.B. has a history of asthma but has not used any
medications for approximately four years.
Medications: Amlodipine 10 mg PO once daily for hypertension
Lisinopril 10 mg PO once daily for hypertension
Previous Medical - Breast cancer, left mastectomy (1991)
History:
Allergies: Allergic to cats (sneezing, nose congestion, coughing)
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Chronic hypertension
Illnesses/Major
Traumas: - Asthma
Hospitalizations/ The patient receives regular medical care, visiting her oncologist
Surgeries:
and her primary care provider three times a year, except when
experiencing exacerbations of chronic disease or flu symptoms.
She has undergone surgeries in the past:
- Breast cancer, left mastectomy (1991)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 71 from CKD
History of HF, CKD, gout
MGM History of gout
(Maternal
Grandmother):
MGF (Maternal History of hypertension
Grandfather):
