NR511.Week7.SOAP
NR511.Week7.SOAP
Patient: Katie, 65 y/o Caucasian female
CC: “Fatigue.”
Subjective:
HPI:
Onset: About a month ago.
Location: General malaise/fatigue of whole body.
Duration: Constant.
Characteristics: None stated.
Aggravating factors: Waking up at 4 am every day and can’t get back to sleep.
Relieving factors: None stated. Have you tried anything to help you relax and fall asleep?
Treatment: Have you taken anything to help you sleep better?
Severity: When wakes up wants to go back to sleep and can’t get back to sleep?
Additional Questions: How is your appetite? She doesn’t have an appetite. Any weight loss or
gain? Have you had any thoughts of suicide?
Current Diagnoses: Osteopenia, Hyperlipidemia, and HTN.
Current Medications: Multivitamin daily, Evista 60 mg daily, HCTZ 25 mg daily, Allegra
PRN.
Allergies: Demerol = vomiting. Seasonal allergies to pollen and hay fever. Any food allergies?
Past Medical History: Chicken pox, measles and rubella during childhood. Osteopenia, HTN,
and hyperlipidemia. Up to date on vaccinations.
, NR511.Week7.SOAP
Past Surgeries/Hospitalizations: Tonsillectomy and cholecystectomy. Hospitalized for
childbirth and surgeries.
Social History: Lives with husband of 45 years John, and married daughter and her family.
Watches grandkids when Mary and her husband are at work. Her husband and Mary’s husband
smoke but not in the house.
NR511.Week7.SOAP
Patient: Katie, 65 y/o Caucasian female
CC: “Fatigue.”
Subjective:
HPI:
Onset: About a month ago.
Location: General malaise/fatigue of whole body.
Duration: Constant.
Characteristics: None stated.
Aggravating factors: Waking up at 4 am every day and can’t get back to sleep.
Relieving factors: None stated. Have you tried anything to help you relax and fall asleep?
Treatment: Have you taken anything to help you sleep better?
Severity: When wakes up wants to go back to sleep and can’t get back to sleep?
Additional Questions: How is your appetite? She doesn’t have an appetite. Any weight loss or
gain? Have you had any thoughts of suicide?
Current Diagnoses: Osteopenia, Hyperlipidemia, and HTN.
Current Medications: Multivitamin daily, Evista 60 mg daily, HCTZ 25 mg daily, Allegra
PRN.
Allergies: Demerol = vomiting. Seasonal allergies to pollen and hay fever. Any food allergies?
Past Medical History: Chicken pox, measles and rubella during childhood. Osteopenia, HTN,
and hyperlipidemia. Up to date on vaccinations.
, NR511.Week7.SOAP
Past Surgeries/Hospitalizations: Tonsillectomy and cholecystectomy. Hospitalized for
childbirth and surgeries.
Social History: Lives with husband of 45 years John, and married daughter and her family.
Watches grandkids when Mary and her husband are at work. Her husband and Mary’s husband
smoke but not in the house.
