SOAP NOTE
Student Name: Course: NSG6420
Name: Date: 1/16/2024 Time: 1115
Ethnicity: Hispanic Age: 36 Sex: F
SUBJECTIVE
CC: “My nose is swollen where I have my piercing”
HPI: The 36 year old Hispanic female patient reports redness and swelling with pus filled
acne at site of left nostril piercing. She has not used medication at site of piercing, denies
fever and chills.
Medications: (list with reason for med )
None
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Breast augmentation
Family History
M: Alive- Breast cancer survivor
MGM: Alive
MGF: Deceased
F: Alive- hypertension
PGM: Alive
, PGF Deceased
Social History
A 36-year-old female patient, professionally employed as a full-time nurse, presents as well-
dressed and mannered. She is divorced and shares co-parenting responsibilities for her two
children with her ex-husband.
ROS
General Cardiovascular
Patient denies nights sweats, fever, chills and Denies any chest pain or shortness of breath.
fatigue
Skin Respiratory
New skin lesion Denies shortness of breath, reports
chest congestion, productive cough
Eyes Gastrointestinal
Denies any visual changes, complains of pain Reports heart burn and regurgitation of food,
behind bilateral eyes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
Nose/Mouth/Throat Musculoskeletal
Reports redness and tenderness at nose, denies Denies pain to extremities or difficulty
throat or mouth pain ambulating
Student Name: Course: NSG6420
Name: Date: 1/16/2024 Time: 1115
Ethnicity: Hispanic Age: 36 Sex: F
SUBJECTIVE
CC: “My nose is swollen where I have my piercing”
HPI: The 36 year old Hispanic female patient reports redness and swelling with pus filled
acne at site of left nostril piercing. She has not used medication at site of piercing, denies
fever and chills.
Medications: (list with reason for med )
None
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Breast augmentation
Family History
M: Alive- Breast cancer survivor
MGM: Alive
MGF: Deceased
F: Alive- hypertension
PGM: Alive
, PGF Deceased
Social History
A 36-year-old female patient, professionally employed as a full-time nurse, presents as well-
dressed and mannered. She is divorced and shares co-parenting responsibilities for her two
children with her ex-husband.
ROS
General Cardiovascular
Patient denies nights sweats, fever, chills and Denies any chest pain or shortness of breath.
fatigue
Skin Respiratory
New skin lesion Denies shortness of breath, reports
chest congestion, productive cough
Eyes Gastrointestinal
Denies any visual changes, complains of pain Reports heart burn and regurgitation of food,
behind bilateral eyes Denies abdominal pain, nausea, vomiting or
diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
Nose/Mouth/Throat Musculoskeletal
Reports redness and tenderness at nose, denies Denies pain to extremities or difficulty
throat or mouth pain ambulating
