CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient B.Z Time: 06:53 pm
Name
(Initials
ONLY):
Date: 01/09/2026 Sex: male
Age: 62 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “My right ear is killing me. It’s been itchy and irritated for five
days, but today the pain is unbearable, especially when I'm
chewing. It feels completely plugged up, and I can barely hear out
of it. The inside of my ear feels swollen and heavy.”
HPI: B.Z., a 62-year-old male, reports experiencing constant pain in his
right ear for the past five days, which has progressively worsened
in intensity since the onset. He describes the pain as both sharp and
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
aching, accompanied by pruritus and mild hearing loss in his right
ear. The pain intensifies when he chews or lies on the affected side.
Although he tried over-the-counter ibuprofen, it provided only
minimal relief. He rates the pain severity as 8/10 on the pain scale,
particularly during jaw movement. The patient denies having fever,
dizziness, tinnitus, otorrhea, headache, or any upper respiratory
symptoms.
Medications: Metformin 500 mg PO once daily with the evening meal
Duration: chronic administration for diabetes.
SE: diarrhea, nausea, stomach pain, hypoglycemia.
Teaching: take with a meal to minimize side effects and
at the same time every day, maintain adequate
hydration, and get regular check up to
evaluate blood sugar level and kidney
function.
Lisinopril 20 mg PO once daily
Duration: chronic administration for hypertension.
SE: dry cough, dizziness, hypotension.
Teaching: report any swelling of the face, lips, or
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
tongue; do not stop abruptly.
Previous Medical - COVID-19 (2020)
History:
- Appendectomy (1987)
Allergies: Peanut allergy (skin redness, itching)
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Type 2 Diabetes Mellitus
- Atopic dermatitis
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider two times a year, except when experiencing exacerbations
of chronic disease or flu symptoms. He has undergone surgeries in
the past:
- Appendectomy (1987)
Student Course: NSG6420-Practicum I:
Name: Family Health – Adults &
Gerontology
Patient B.Z Time: 06:53 pm
Name
(Initials
ONLY):
Date: 01/09/2026 Sex: male
Age: 62 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “My right ear is killing me. It’s been itchy and irritated for five
days, but today the pain is unbearable, especially when I'm
chewing. It feels completely plugged up, and I can barely hear out
of it. The inside of my ear feels swollen and heavy.”
HPI: B.Z., a 62-year-old male, reports experiencing constant pain in his
right ear for the past five days, which has progressively worsened
in intensity since the onset. He describes the pain as both sharp and
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
aching, accompanied by pruritus and mild hearing loss in his right
ear. The pain intensifies when he chews or lies on the affected side.
Although he tried over-the-counter ibuprofen, it provided only
minimal relief. He rates the pain severity as 8/10 on the pain scale,
particularly during jaw movement. The patient denies having fever,
dizziness, tinnitus, otorrhea, headache, or any upper respiratory
symptoms.
Medications: Metformin 500 mg PO once daily with the evening meal
Duration: chronic administration for diabetes.
SE: diarrhea, nausea, stomach pain, hypoglycemia.
Teaching: take with a meal to minimize side effects and
at the same time every day, maintain adequate
hydration, and get regular check up to
evaluate blood sugar level and kidney
function.
Lisinopril 20 mg PO once daily
Duration: chronic administration for hypertension.
SE: dry cough, dizziness, hypotension.
Teaching: report any swelling of the face, lips, or
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
tongue; do not stop abruptly.
Previous Medical - COVID-19 (2020)
History:
- Appendectomy (1987)
Allergies: Peanut allergy (skin redness, itching)
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Type 2 Diabetes Mellitus
- Atopic dermatitis
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider two times a year, except when experiencing exacerbations
of chronic disease or flu symptoms. He has undergone surgeries in
the past:
- Appendectomy (1987)
