CONPH NSG6020 Week 5-9 SOAP NOTES (in 1 pdf) Complete
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Psychiatric: AOX3,
Neurological: PEERLA, cranial
Neat appearance, nerves
behavior tested
and andappropriate.
speech intact. No tremors noted.
Mood and Memory
affect normalintact.
and appropriate to
situation. Patient is pleasant and cooperative. Speech clear. Good tone. Posture erects. Balance stable.
Lab Tests: BAL_ 46.0 CMP_ Creatinine 2.4, BUN 16, Ca+ 8.0, Mag 1.3, AST 274, ALT 93_Alkaline phosphatw_263,
albumin 3.5, billi 3.2, Lactate_ 8.3 WBC_136. Hemoglobin 15.2, NA+ 132, Troponin 131, CK 4113, H & H 15.2/43.9 TSH
2.7,
Special Tests: Urinalysis showed traces of glucose 1+ protein, 2+ blood, 250 leukocytes esterase few bacteria
DIAGNOSIS
Differential Diagnoses Diagnosis
1- Diagnosis, (ICD 10 code): M62.82 1- Presumptive diagnosis (ICD 10 code): N19. AKI
Rhabdomyolysis 2nd to mechanical fall in the on CKD 2nd to above
setting of alcohol intoxication
1- Diagnosis, (ICD 10 code): E86.20 Lactic
acidosis 2nd to above
Plan/Therapeutics:Iv fluids LR for rehydration, Monitor CK, Lactate, Troponin, stop metformin until creatinine and
lactate level trended down. Bruises and abrasion cared for appropriately
Diagnostics:EKG sinus tachycardia, Renal ultrasound complete with normal findings
CT head wo Iv contrast no acute intracranial abnormality
Education:: Education was provided on cessation of alcohol consumption " He stated he decided to quit". To follow-up
with cardiologist, nephrology and gastroenterology to address his management SOB on exertion, fatigue, and mild
edema associated with obesity . Education provides a healthy and diabetic diet and exercise to lose weight.
Student Name:Yolanda McBride Course: NSG 6020
Patient Name: (Initials ONLY) W.B. Date:6/23/2025 Time: 1100
Ethnicity: White Age: 72 Sex: Male
SUBJECTIVE (must complete this section)
CC: Fall had a ground level fall and has abrasions to knees(Patient does not remember falling and unsure if he had any
LOC)
HPI: 72 y/o male fall occurred at home.
Medications:Amlodipine 5mg po daily, ASA 81mg po daily, Synthroid 20mcg po daily before breakfast, Metformin 1,000
mg po BID, Mounjaro 0.5mg subq 1 x week, Norc 7.5-325mg 1 tab po q6hrs prn, pyridoxine 50mg po daily, Flomax
0.4mg po daily, Thiamine 100mg po daily, and Bumex 2mg po daily, Klor-Con 20 meq po daily.
Previous Medical History:DM 2, Legally blind, Arthritis, SOB on exertion, hypothyroidism, chronic kidney disease,
chronic alcohol abuse.
Allergies:NKDA
Medication Intolerances:No medication intolerances
Chronic Illnesses/Major traumas:
Hospitalizations/Surgeries:Cataract extraction, Right Shoulder 4/24,Thyroid s/p 2014
FAMILY HISTORY (must complete this section)
M:Unknown
MGM:Unknown
MGF:Unknown
F:Unknown
PGM:Unknown
PGF:Unknown
10122023 Page 1 of 3
, CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Social History:Patient is retired and live at home by himself, has groceries delivered to home. States drinks at least 1
beer daily with dinner and 28oz of whiskey on a regular basis. Denies smoking or illicit drug abuse. Patient has chronic
hs of alcohol abuse; thus, reported he drank 1.45L of whiskey in 3 days.
REVIEW OF SYSTEMS (must complete this section)
General:States have mild fatigue on exertion. Denies Cardiovascular:Denies chest pain, palpitations, PND,
orthopnea, or edema
fever, chills, night sweats, or altered energy level
Skin:Denies delayed healing, rashes, bruising, bleeding or Respiratory:Positive SOB on exertion. Denies cough,
skin discolorations, and no changes in lesions or moles
wheezing, hemoptysis, dyspnea, pneumonia history, or TB
Eyes:States that he does wear corrective lenses (Glasses). Gastrointestinal:Denies abdominal pain, N/V/D,
No blurring, or visual changes of any kind. constipation, hepatitis, hemorrhoids, eating disorders,
ulcers, or black tarry stools
Ears:Denies ear pain, hearing loss, ringing in ears, or Genitourinary/Gynecological:Denies urgency, frequency
burning, change in color of urine, or discharge. Denies
discharge
sexual activity, or STDS.
Nose/Mouth/Throat:Denies sinus problems, dysphagia, Musculoskeletal:Denies any joint stiffness or pain. H/o left
nose bleeds or discharge, dental disease, hoarseness, or shoulder fx 2023, physical deconditioning.
throat pain
Breast:Denies SBE, lumps, bumps or changes Neurological:Denies syncope, seizures, transient paralysis,
weakness, parenthesis, or black out spells.
Heme/Lymph/Endo:Denies positive HIV status, bruising, Psychiatric:Denies positive HIV status, bruising,
blood transfusion history, night sweats, swollen glands, blood transfusion history, night sweats, swollen glands,
increase thirst, increase hunger, cold or heat intolerance. increase thirst, increase hunger, cold or heat intolerance.
OBJECTIVE (Document PERTINENT systems only. Minimum 3)
Weight: 265.5 Height:6'0 BMI:36.0 BP:129/86 Temp:98 Pulse:107 Resp:19
General Appearance: Pt appears to be stated age, well-nourished, but in apparent pain. Pt is well-groomed, clean, and
dressed appropriately. Facial expressions are appropriate to a situation.
Skin:Skin warm and dry, have scattered bruising across upper extremities and knees. Dressing over bilateral knees
HEENT:
Cardiovascular:HR NSR, S1, S2 with regular rate and rhythm, no murmur noted. No extra sounds, clicks, rubs or
murmurs. Pulses 3+ throughout. Stable RLE 1 + at ankle and Stable LLE edema 2+ up 2/3 of shin. Bilateral dorsalis
pedis +1. Cap refill <2 sec in all four extremities.
Respiratory:No cough, B/L BS clear in all fields, respirations are unlabored, no use of accessory muscles. No pain
related to respiration.
Gastrointestinal:Abdomen soft/ no lower abdomen tenderness, no visual peristalsis or palpitations. BS present in all
four quadrants. No mass noted.
Breast: Denies SBE, lumps, bumps or changes
Genitourinary: Denies urgency, frequency burning, change in color of urine, or discharge.
10122023 Page 2 of 3
, CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Musculoskeletal: Full active ROM, gait balanced and steady with the use of a cane. No weakness or atrophy. Lower
right back pain on palpation, when bending down, and with walking or standing for long periods of time. Uses cane for
ambulation.
10122023 Page 3 of 3
CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Psychiatric: AOX3,
Neurological: PEERLA, cranial
Neat appearance, nerves
behavior tested
and andappropriate.
speech intact. No tremors noted.
Mood and Memory
affect normalintact.
and appropriate to
situation. Patient is pleasant and cooperative. Speech clear. Good tone. Posture erects. Balance stable.
Lab Tests: BAL_ 46.0 CMP_ Creatinine 2.4, BUN 16, Ca+ 8.0, Mag 1.3, AST 274, ALT 93_Alkaline phosphatw_263,
albumin 3.5, billi 3.2, Lactate_ 8.3 WBC_136. Hemoglobin 15.2, NA+ 132, Troponin 131, CK 4113, H & H 15.2/43.9 TSH
2.7,
Special Tests: Urinalysis showed traces of glucose 1+ protein, 2+ blood, 250 leukocytes esterase few bacteria
DIAGNOSIS
Differential Diagnoses Diagnosis
1- Diagnosis, (ICD 10 code): M62.82 1- Presumptive diagnosis (ICD 10 code): N19. AKI
Rhabdomyolysis 2nd to mechanical fall in the on CKD 2nd to above
setting of alcohol intoxication
1- Diagnosis, (ICD 10 code): E86.20 Lactic
acidosis 2nd to above
Plan/Therapeutics:Iv fluids LR for rehydration, Monitor CK, Lactate, Troponin, stop metformin until creatinine and
lactate level trended down. Bruises and abrasion cared for appropriately
Diagnostics:EKG sinus tachycardia, Renal ultrasound complete with normal findings
CT head wo Iv contrast no acute intracranial abnormality
Education:: Education was provided on cessation of alcohol consumption " He stated he decided to quit". To follow-up
with cardiologist, nephrology and gastroenterology to address his management SOB on exertion, fatigue, and mild
edema associated with obesity . Education provides a healthy and diabetic diet and exercise to lose weight.
Student Name:Yolanda McBride Course: NSG 6020
Patient Name: (Initials ONLY) W.B. Date:6/23/2025 Time: 1100
Ethnicity: White Age: 72 Sex: Male
SUBJECTIVE (must complete this section)
CC: Fall had a ground level fall and has abrasions to knees(Patient does not remember falling and unsure if he had any
LOC)
HPI: 72 y/o male fall occurred at home.
Medications:Amlodipine 5mg po daily, ASA 81mg po daily, Synthroid 20mcg po daily before breakfast, Metformin 1,000
mg po BID, Mounjaro 0.5mg subq 1 x week, Norc 7.5-325mg 1 tab po q6hrs prn, pyridoxine 50mg po daily, Flomax
0.4mg po daily, Thiamine 100mg po daily, and Bumex 2mg po daily, Klor-Con 20 meq po daily.
Previous Medical History:DM 2, Legally blind, Arthritis, SOB on exertion, hypothyroidism, chronic kidney disease,
chronic alcohol abuse.
Allergies:NKDA
Medication Intolerances:No medication intolerances
Chronic Illnesses/Major traumas:
Hospitalizations/Surgeries:Cataract extraction, Right Shoulder 4/24,Thyroid s/p 2014
FAMILY HISTORY (must complete this section)
M:Unknown
MGM:Unknown
MGF:Unknown
F:Unknown
PGM:Unknown
PGF:Unknown
10122023 Page 1 of 3
, CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Social History:Patient is retired and live at home by himself, has groceries delivered to home. States drinks at least 1
beer daily with dinner and 28oz of whiskey on a regular basis. Denies smoking or illicit drug abuse. Patient has chronic
hs of alcohol abuse; thus, reported he drank 1.45L of whiskey in 3 days.
REVIEW OF SYSTEMS (must complete this section)
General:States have mild fatigue on exertion. Denies Cardiovascular:Denies chest pain, palpitations, PND,
orthopnea, or edema
fever, chills, night sweats, or altered energy level
Skin:Denies delayed healing, rashes, bruising, bleeding or Respiratory:Positive SOB on exertion. Denies cough,
skin discolorations, and no changes in lesions or moles
wheezing, hemoptysis, dyspnea, pneumonia history, or TB
Eyes:States that he does wear corrective lenses (Glasses). Gastrointestinal:Denies abdominal pain, N/V/D,
No blurring, or visual changes of any kind. constipation, hepatitis, hemorrhoids, eating disorders,
ulcers, or black tarry stools
Ears:Denies ear pain, hearing loss, ringing in ears, or Genitourinary/Gynecological:Denies urgency, frequency
burning, change in color of urine, or discharge. Denies
discharge
sexual activity, or STDS.
Nose/Mouth/Throat:Denies sinus problems, dysphagia, Musculoskeletal:Denies any joint stiffness or pain. H/o left
nose bleeds or discharge, dental disease, hoarseness, or shoulder fx 2023, physical deconditioning.
throat pain
Breast:Denies SBE, lumps, bumps or changes Neurological:Denies syncope, seizures, transient paralysis,
weakness, parenthesis, or black out spells.
Heme/Lymph/Endo:Denies positive HIV status, bruising, Psychiatric:Denies positive HIV status, bruising,
blood transfusion history, night sweats, swollen glands, blood transfusion history, night sweats, swollen glands,
increase thirst, increase hunger, cold or heat intolerance. increase thirst, increase hunger, cold or heat intolerance.
OBJECTIVE (Document PERTINENT systems only. Minimum 3)
Weight: 265.5 Height:6'0 BMI:36.0 BP:129/86 Temp:98 Pulse:107 Resp:19
General Appearance: Pt appears to be stated age, well-nourished, but in apparent pain. Pt is well-groomed, clean, and
dressed appropriately. Facial expressions are appropriate to a situation.
Skin:Skin warm and dry, have scattered bruising across upper extremities and knees. Dressing over bilateral knees
HEENT:
Cardiovascular:HR NSR, S1, S2 with regular rate and rhythm, no murmur noted. No extra sounds, clicks, rubs or
murmurs. Pulses 3+ throughout. Stable RLE 1 + at ankle and Stable LLE edema 2+ up 2/3 of shin. Bilateral dorsalis
pedis +1. Cap refill <2 sec in all four extremities.
Respiratory:No cough, B/L BS clear in all fields, respirations are unlabored, no use of accessory muscles. No pain
related to respiration.
Gastrointestinal:Abdomen soft/ no lower abdomen tenderness, no visual peristalsis or palpitations. BS present in all
four quadrants. No mass noted.
Breast: Denies SBE, lumps, bumps or changes
Genitourinary: Denies urgency, frequency burning, change in color of urine, or discharge.
10122023 Page 2 of 3
, CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Musculoskeletal: Full active ROM, gait balanced and steady with the use of a cane. No weakness or atrophy. Lower
right back pain on palpation, when bending down, and with walking or standing for long periods of time. Uses cane for
ambulation.
10122023 Page 3 of 3
