CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient A.B. Time: 08:14 pm
Name
(Initials
ONLY):
Date: 01/16/2026 Sex: female
Age: 68 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “When I climb stairs, walk quickly, or play with my grandkids, my
chest feels tight, I can’t breathe, and my heart feels like it’s racing.
This has happened three times over the past months. I’ve also
noticed new swelling in my legs.”
HPI: A.B., a 68-year-old female reports experiencing chest pain
described as a tightening sensation, dyspnea with exertion, and
palpitation events that happened three times over the past months.
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Additionally, she noticed a new onset of bilateral extremity edema.
She does not report experiencing pain radiation and dyspnea at
rest, fatigue, dizziness, or headache. The patient has been taking
blood pressure medication daily for the past six years, but she does
not monitor her blood pressure at home. Her medical history
includes long-standing hypertension, a hiatal hernia, and a recent
sensation of heartburn for which she takes Maalox. The last PCP
visit with blood work was three months ago.
Medications: Amlodipine 10 mg PO once daily for hypertension
Maalox 2 chewable tablets for heartburn as needed
Previous Medical - COVID-19 (2020, 2021)
History:
- Cholecystectomy (2021)
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Traumas: - Diaphragmatic hernia
- Obesity
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider three times a year, except when experiencing
exacerbations of chronic disease or flu symptoms. He has
undergone surgeries in the past:
- cholecystectomy (2021)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 72 from CHF
History of HF
MGM History of hypertension
(Maternal
Grandmother):
MGF (Maternal History of hypertension
Grandfather):
F (Father): Father is deceased at 76 from CHF
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient A.B. Time: 08:14 pm
Name
(Initials
ONLY):
Date: 01/16/2026 Sex: female
Age: 68 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “When I climb stairs, walk quickly, or play with my grandkids, my
chest feels tight, I can’t breathe, and my heart feels like it’s racing.
This has happened three times over the past months. I’ve also
noticed new swelling in my legs.”
HPI: A.B., a 68-year-old female reports experiencing chest pain
described as a tightening sensation, dyspnea with exertion, and
palpitation events that happened three times over the past months.
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Additionally, she noticed a new onset of bilateral extremity edema.
She does not report experiencing pain radiation and dyspnea at
rest, fatigue, dizziness, or headache. The patient has been taking
blood pressure medication daily for the past six years, but she does
not monitor her blood pressure at home. Her medical history
includes long-standing hypertension, a hiatal hernia, and a recent
sensation of heartburn for which she takes Maalox. The last PCP
visit with blood work was three months ago.
Medications: Amlodipine 10 mg PO once daily for hypertension
Maalox 2 chewable tablets for heartburn as needed
Previous Medical - COVID-19 (2020, 2021)
History:
- Cholecystectomy (2021)
Allergies: NKA
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Traumas: - Diaphragmatic hernia
- Obesity
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider three times a year, except when experiencing
exacerbations of chronic disease or flu symptoms. He has
undergone surgeries in the past:
- cholecystectomy (2021)
FAMILY HISTORY (must complete this section)
M (Mother): Mother is deceased at 72 from CHF
History of HF
MGM History of hypertension
(Maternal
Grandmother):
MGF (Maternal History of hypertension
Grandfather):
F (Father): Father is deceased at 76 from CHF
