@PROFDOCDIGITALLIBRARIES
NU 518 Comprehensive SOAP Note- CJ 27-YEAR OLD
Graded A+ 2023-
2024 Updated
Version
Comprehensive SOAP Note
July 10th, 2019 @ 1030 AM
Patient Information: CJ is a pleasant, 27-year-old married, Caucasian male currently residing in
Andalusia, Alabama. Insured by Blue Cross and Blue Shield of Alabama.
Referral & Reliability: Self-referred and seems reliable.
PR
S – Subjective Data
Chief Complaint: “I keep having heartburn after eating.”
HPI:
• Location – Upper stomach, chest, and throat. Pain does not radiate.
O
• Quality – “Burning sensation.”
• Quantity/Severity – Discomfort from burning sensation is 4 on 0-10 pain scale.
• Timing – Sudden onset 2 weeks ago after eating Mexican food; reoccurring episodes 2-3
FD
times weekly since initial episode after eating spicy or greasy foods; can last 2 hours or
longer.
• Setting/Context – Patient believes “spicy Mexican food irritated his stomach triggering
heartburn.”
• Aggravating or Relieving Factors – Spicy or greasy food, drinking soft drinks, and
O
using smokeless tobacco worsen symptoms. Taking OTC Tums helps relieve symptoms.
• Self-Treatment – OTC Tums 750 mg, 2 tabs by mouth at the onset of symptoms; some
relief after about 2 hours after taking Tums
C
• Past Medical, Family, or Social History related to CC/HP – Patient consumes fast
food almost daily, drinks 3-4 caffeinated beverages daily, and uses 1 can smokeless
tobacco daily. No pertinent family Hx assessed.
PMHx:
• Childhood Illnesses – Chickenpox (1997). Denies other childhood illnesses.
• Major Adult Illnesses – Migraines (onset 2008) Controlled with medication – see listed
below; idiopathic elevated liver enzymes (onset 2018). Denies other adult illnesses.
• Immunizations – Immunizations are “up to date from previous employment overseas.”
Tdap 2018; HBV 2018; Pneumonia 2018; Influenza 2018; Polio 2018; Pertussis 2016;
Diphtheria 2018; MMR 2018; Denies having HPV vac.
• Health Maintenance Screenings – TB skin test 2018, stool for occult blood 2018, eye
exam 2018, hearing test 2018, prostate exam 2018, cholesterol screening 2018, hepatic
panel 2018
• Hospitalizations/Surgeries
o 2014 observation admit for “separated clavicle from a snowboarding accident.”
, @PROFDOCDIGITALLIBRARIES
o 2011 observation admit for “arm injury from wakeboarding accident.”
o 2009 surgical admit for “ACL repair of the left knee.”
• Injuries/Accidents – See above. Denies other injuries/accidents.
PR
O
FD
O
C
NU 518 Comprehensive SOAP Note- CJ 27-YEAR OLD
Graded A+ 2023-
2024 Updated
Version
Comprehensive SOAP Note
July 10th, 2019 @ 1030 AM
Patient Information: CJ is a pleasant, 27-year-old married, Caucasian male currently residing in
Andalusia, Alabama. Insured by Blue Cross and Blue Shield of Alabama.
Referral & Reliability: Self-referred and seems reliable.
PR
S – Subjective Data
Chief Complaint: “I keep having heartburn after eating.”
HPI:
• Location – Upper stomach, chest, and throat. Pain does not radiate.
O
• Quality – “Burning sensation.”
• Quantity/Severity – Discomfort from burning sensation is 4 on 0-10 pain scale.
• Timing – Sudden onset 2 weeks ago after eating Mexican food; reoccurring episodes 2-3
FD
times weekly since initial episode after eating spicy or greasy foods; can last 2 hours or
longer.
• Setting/Context – Patient believes “spicy Mexican food irritated his stomach triggering
heartburn.”
• Aggravating or Relieving Factors – Spicy or greasy food, drinking soft drinks, and
O
using smokeless tobacco worsen symptoms. Taking OTC Tums helps relieve symptoms.
• Self-Treatment – OTC Tums 750 mg, 2 tabs by mouth at the onset of symptoms; some
relief after about 2 hours after taking Tums
C
• Past Medical, Family, or Social History related to CC/HP – Patient consumes fast
food almost daily, drinks 3-4 caffeinated beverages daily, and uses 1 can smokeless
tobacco daily. No pertinent family Hx assessed.
PMHx:
• Childhood Illnesses – Chickenpox (1997). Denies other childhood illnesses.
• Major Adult Illnesses – Migraines (onset 2008) Controlled with medication – see listed
below; idiopathic elevated liver enzymes (onset 2018). Denies other adult illnesses.
• Immunizations – Immunizations are “up to date from previous employment overseas.”
Tdap 2018; HBV 2018; Pneumonia 2018; Influenza 2018; Polio 2018; Pertussis 2016;
Diphtheria 2018; MMR 2018; Denies having HPV vac.
• Health Maintenance Screenings – TB skin test 2018, stool for occult blood 2018, eye
exam 2018, hearing test 2018, prostate exam 2018, cholesterol screening 2018, hepatic
panel 2018
• Hospitalizations/Surgeries
o 2014 observation admit for “separated clavicle from a snowboarding accident.”
, @PROFDOCDIGITALLIBRARIES
o 2011 observation admit for “arm injury from wakeboarding accident.”
o 2009 surgical admit for “ACL repair of the left knee.”
• Injuries/Accidents – See above. Denies other injuries/accidents.
PR
O
FD
O
C
