SOAP NOTE
Student Name: Course: NSG6420
Name: Date: 1/6/2024 Time: 0930
Ethnicity: Middle Eastern Age: 68 Sex: F
SUBJECTIVE
CC: “I have been having knee pain for 6 months”
HPI: A 70-year-old Middle Eastern female presents today with a chief complaint of
persistent knee pain that has been troubling her for the last 6 months. According to the
patient, the pain initially started gradually and has progressively worsened over time. She
describes the pain as a dull ache, primarily localized to the medial aspect of the right knee.
The patient notes that the pain is exacerbated during weight-bearing activities, such as
walking or standing for prolonged periods. There is no specific history of trauma or injury to
the knee. She reports occasional stiffness in the affected knee, especially upon waking in the
morning. The patient denies any significant swelling, redness, or warmth around the knee
joint.
Medications: (list with reason for med )
Simvastatin 40 mg daily
Amlodipine 5 mg daily
PMH
Allergies: Penicillin- Rash
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hyperlipidemia, Hypertension
Hospitalizations/Surgeries- Hysterectomy, Right hip replacement
Family History
M: Deceased- Cardiac
, MGM: Deceased MGF: Deceased
F: Deceased- cardiac PGM: deceased
PGF Deceased
Social History
A 70-year-old Middle Eastern widow has been an active member of her community since
migrating to the USA. With a background in Social Work, she retired 9 years ago, now
enjoying literature, community activities, and maintaining close connections with her 2
children.
ROS
General Cardiovascular
Patient denies nights sweats and fatigue Denies any chest pain or shortness of breath.
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies shortness of breath, reports
chest congestion, productive cough
Eyes Gastrointestinal
Denies any visual changes, complains of pain Denies abdominal pain, nausea, vomiting or
behind bilateral eyes diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
Student Name: Course: NSG6420
Name: Date: 1/6/2024 Time: 0930
Ethnicity: Middle Eastern Age: 68 Sex: F
SUBJECTIVE
CC: “I have been having knee pain for 6 months”
HPI: A 70-year-old Middle Eastern female presents today with a chief complaint of
persistent knee pain that has been troubling her for the last 6 months. According to the
patient, the pain initially started gradually and has progressively worsened over time. She
describes the pain as a dull ache, primarily localized to the medial aspect of the right knee.
The patient notes that the pain is exacerbated during weight-bearing activities, such as
walking or standing for prolonged periods. There is no specific history of trauma or injury to
the knee. She reports occasional stiffness in the affected knee, especially upon waking in the
morning. The patient denies any significant swelling, redness, or warmth around the knee
joint.
Medications: (list with reason for med )
Simvastatin 40 mg daily
Amlodipine 5 mg daily
PMH
Allergies: Penicillin- Rash
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hyperlipidemia, Hypertension
Hospitalizations/Surgeries- Hysterectomy, Right hip replacement
Family History
M: Deceased- Cardiac
, MGM: Deceased MGF: Deceased
F: Deceased- cardiac PGM: deceased
PGF Deceased
Social History
A 70-year-old Middle Eastern widow has been an active member of her community since
migrating to the USA. With a background in Social Work, she retired 9 years ago, now
enjoying literature, community activities, and maintaining close connections with her 2
children.
ROS
General Cardiovascular
Patient denies nights sweats and fatigue Denies any chest pain or shortness of breath.
Skin Respiratory
No rash, lesions, or other skin abnormalities Denies shortness of breath, reports
chest congestion, productive cough
Eyes Gastrointestinal
Denies any visual changes, complains of pain Denies abdominal pain, nausea, vomiting or
behind bilateral eyes diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
