Week 1 Shadow Health SOAP Note course hero
SOAP Note Week 1
S: Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and
reaction)
Rating
170 90 kg 142/ 86 19 101.1 99% Medication: Penicillin (hives,
rash) Food: None
cm 82 F
Environment: Cats, dust (asthma flare up, sneezing, itchy eyes)
History of Present Illness (HPI)
Chief Complaint (CC) Infected right foot wound CC is a BRIEF statement identifying
why the patient is here - in the
Onset 1 week ago
patient’s own words - for instance
Location Bottom of right foot "headache", NOT "bad headache for 3
days”. Sometimes a patient has more
Duration 1 week and a few days, constant
than one complaint. For example: If
Characteristics Swollen near the scrape, open, red, and painful with increased pain the patient presents with cough and
,Week 1 Shadow Health SOAP Note course hero
when walking on it sore throat, identify which is the CC
and which may be an associated
Aggravating Factors Walking, movement, weight-bearing
symptom
Relieving Factors Resting and pain medications
Treatment Tramadol 50 mg PO, Clean wound with hydrogen peroxide, application
of
topical ointment, covered with bandage, BID
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
Used
(Rx, OTC, or Homeopathic)
Ibuprofen 200 mg Q 6 hrs PRN PRN PRN for menstrual pain
Proventil 90 mcg 2 puffs TID PRN PRN since PRN for asthma symptoms
childhood
Tramadol 50 mg Q 8 hrs PRN PRN PRN for foot wound pain
Acetaminophen 500-1000 mg Q 6 hrs PRN PRN PRN for headaches
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, Week 1 Shadow Health SOAP Note course hero
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Asthma since childhood. She uses her albuterol inhaler when exposed to cats and dust. She reports using her inhaler 2-3 times
per week. She was exposed to a cat 1 week ago and used her albuterol inhaler with positive relief of symptoms. Type 2 diabetes
since age 24, she previously took metformin but stopped taking it due to unwanted side effects of gas and a sense of being
overwhelmed by taking pills and having to monitor her blood glucose. She does not monitor her blood glucose. Her blood glucose
was high last week at her ER visit and is elevated in office visit today at
238. No hx of surgeries, last hospital admission as a child for asthma exacerbation. Immunization status up to date. Last tetanus
vaccine: 05/01/2021 (1 week ago).
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Accounting student. Lives with her sister and mother to support each other after father’s death one year ago. Brother lives
elsewhere, and father is deceased. She enjoys spending time with her family and friends and attending church. Denies tobacco
use. Occasional cannabis use in adolescence and young adulthood but stopped at age 21. Denies illicit drug use. Drinks rum
and coke 2-3 times per month socially when out with friends, reports drinking no more than 3 drinks per episode. Last sexual
encounter was 2 years ago. Single, never married. No children.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
SOAP Note Week 1
S: Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies (and
reaction)
Rating
170 90 kg 142/ 86 19 101.1 99% Medication: Penicillin (hives,
rash) Food: None
cm 82 F
Environment: Cats, dust (asthma flare up, sneezing, itchy eyes)
History of Present Illness (HPI)
Chief Complaint (CC) Infected right foot wound CC is a BRIEF statement identifying
why the patient is here - in the
Onset 1 week ago
patient’s own words - for instance
Location Bottom of right foot "headache", NOT "bad headache for 3
days”. Sometimes a patient has more
Duration 1 week and a few days, constant
than one complaint. For example: If
Characteristics Swollen near the scrape, open, red, and painful with increased pain the patient presents with cough and
,Week 1 Shadow Health SOAP Note course hero
when walking on it sore throat, identify which is the CC
and which may be an associated
Aggravating Factors Walking, movement, weight-bearing
symptom
Relieving Factors Resting and pain medications
Treatment Tramadol 50 mg PO, Clean wound with hydrogen peroxide, application
of
topical ointment, covered with bandage, BID
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
Used
(Rx, OTC, or Homeopathic)
Ibuprofen 200 mg Q 6 hrs PRN PRN PRN for menstrual pain
Proventil 90 mcg 2 puffs TID PRN PRN since PRN for asthma symptoms
childhood
Tramadol 50 mg Q 8 hrs PRN PRN PRN for foot wound pain
Acetaminophen 500-1000 mg Q 6 hrs PRN PRN PRN for headaches
Click or tap here to enter Click or tap here to Click or tap here to enter Click or tap Click or tap here to enter text.
text. here
enter text. text.
to enter text.
, Week 1 Shadow Health SOAP Note course hero
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Asthma since childhood. She uses her albuterol inhaler when exposed to cats and dust. She reports using her inhaler 2-3 times
per week. She was exposed to a cat 1 week ago and used her albuterol inhaler with positive relief of symptoms. Type 2 diabetes
since age 24, she previously took metformin but stopped taking it due to unwanted side effects of gas and a sense of being
overwhelmed by taking pills and having to monitor her blood glucose. She does not monitor her blood glucose. Her blood glucose
was high last week at her ER visit and is elevated in office visit today at
238. No hx of surgeries, last hospital admission as a child for asthma exacerbation. Immunization status up to date. Last tetanus
vaccine: 05/01/2021 (1 week ago).
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Accounting student. Lives with her sister and mother to support each other after father’s death one year ago. Brother lives
elsewhere, and father is deceased. She enjoys spending time with her family and friends and attending church. Denies tobacco
use. Occasional cannabis use in adolescence and young adulthood but stopped at age 21. Denies illicit drug use. Drinks rum
and coke 2-3 times per month socially when out with friends, reports drinking no more than 3 drinks per episode. Last sexual
encounter was 2 years ago. Single, never married. No children.
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
