NURS 623 SOAP note topic based
adult 2 week 12.
S.O.A.P. Note
Chief Complaint
I’ve had pain in my lower back for a week and it's getting worse.
History of Present Illness
A 42-year-old obese female presents with complaints of lower back pain for the past week that
feels worse today. The pain is constant and intermittently radiates down her left leg. It is not
improved with ibuprofen. She reports that reclining in a recliner helps alleviate the pain and
lying flat makes it worse.
Past Medical History
Past Medical history: None
Past surgical history: None
Patient is current in her immunizations
No known allergies
Current medications include: Ibuprofen 600 mg PO Q4 hours PRN
Family History
Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent
medical illnesses
Mother: Type 2 diabetes, hypertension, hypothyroidism
Father: Asthma, Hypertension
Sister: Hypothyroidism
Personal/Social History
Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if
relevant, exercise, nutrition, religious preference if known
Patient works as grocery store clerk. She is a married heterosexual. Pt denies any alcohol or
illicit drug use. She does not smoke or use chewing tobacco. Pt does not exercise and is on a
regular diet.
Review of Systems (as applicable to CC)
General: Negative for fever. Negative for fatigue. Negative for chills, and night sweats
adult 2 week 12.
S.O.A.P. Note
Chief Complaint
I’ve had pain in my lower back for a week and it's getting worse.
History of Present Illness
A 42-year-old obese female presents with complaints of lower back pain for the past week that
feels worse today. The pain is constant and intermittently radiates down her left leg. It is not
improved with ibuprofen. She reports that reclining in a recliner helps alleviate the pain and
lying flat makes it worse.
Past Medical History
Past Medical history: None
Past surgical history: None
Patient is current in her immunizations
No known allergies
Current medications include: Ibuprofen 600 mg PO Q4 hours PRN
Family History
Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent
medical illnesses
Mother: Type 2 diabetes, hypertension, hypothyroidism
Father: Asthma, Hypertension
Sister: Hypothyroidism
Personal/Social History
Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if
relevant, exercise, nutrition, religious preference if known
Patient works as grocery store clerk. She is a married heterosexual. Pt denies any alcohol or
illicit drug use. She does not smoke or use chewing tobacco. Pt does not exercise and is on a
regular diet.
Review of Systems (as applicable to CC)
General: Negative for fever. Negative for fatigue. Negative for chills, and night sweats
