SOAP NOTE
Student Name: Course: NSG6420
Name: Date: Time: 1115
Ethnicity: White Age: 39 Sex: M
SUBJECTIVE
CC: “I have been having pain/burning in my chest and sour taste in my mouth”
HPI: The patient is a 39-year-old white male who presents with a chief complaint of
epigastric pain and a sour taste in his mouth. He reports that the pain is intermittent and
often occurs after meals, with a duration of approximately two months. The patient
describes the pain as a burning sensation and rates its intensity as moderate. He denies any
radiation of pain and reports occasional regurgitation of stomach contents with a sour taste.
No associated symptoms such as dysphagia, weight loss, or changes in bowel habits are
reported.
Medications: (list with reason for med )
None
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Appendectomy
Family History
M: Alive- Type 2 Diabetes,
hyperlipidemia MGM: Deceased
MGF: Deceased- Colon Cancer
F: Alive- hypertension
, PGM: Alive PGF Alive
Social History
The 39-year-old white male is currently single and resides in an apartment, having worked in
an insurance office for 10 years. He completed his education up to an associates degree. The
patient has a supportive social network and engages in pickle ball for exercise and yoga for
relaxation. There is no history of tobacco or illicit drug use, and he reports minimal alcohol
consumption without any abuse.
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 Reports heart burn and regurgitation of
behind bilateral eyes food, Denies abdominal pain, nausea,
vomiting or diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
Nose/Mouth/Throat Musculoskeletal
Student Name: Course: NSG6420
Name: Date: Time: 1115
Ethnicity: White Age: 39 Sex: M
SUBJECTIVE
CC: “I have been having pain/burning in my chest and sour taste in my mouth”
HPI: The patient is a 39-year-old white male who presents with a chief complaint of
epigastric pain and a sour taste in his mouth. He reports that the pain is intermittent and
often occurs after meals, with a duration of approximately two months. The patient
describes the pain as a burning sensation and rates its intensity as moderate. He denies any
radiation of pain and reports occasional regurgitation of stomach contents with a sour taste.
No associated symptoms such as dysphagia, weight loss, or changes in bowel habits are
reported.
Medications: (list with reason for med )
None
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Denies
Hospitalizations/Surgeries- Appendectomy
Family History
M: Alive- Type 2 Diabetes,
hyperlipidemia MGM: Deceased
MGF: Deceased- Colon Cancer
F: Alive- hypertension
, PGM: Alive PGF Alive
Social History
The 39-year-old white male is currently single and resides in an apartment, having worked in
an insurance office for 10 years. He completed his education up to an associates degree. The
patient has a supportive social network and engages in pickle ball for exercise and yoga for
relaxation. There is no history of tobacco or illicit drug use, and he reports minimal alcohol
consumption without any abuse.
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 Reports heart burn and regurgitation of
behind bilateral eyes food, Denies abdominal pain, nausea,
vomiting or diarrhea
Ears Genitourinary/Gynecological
Denies ear pain or hearing loss Denies discharge, dysuria hematuria.
Nose/Mouth/Throat Musculoskeletal
