SOAP Note Unit 4 Name:
Typhon Encounter #:
NU 610:7D Comprehensive: Focused:
Herzing University
S: SUBJECTIVE DATA
CC: Wellness check
HPI: A 54-year-old white male presents with a history of hypertension.
Hypertension is well controlled with amlodipine.
PMH: Hypertension
ALLERGIES NKDA
MEDICATIONS Amlodipine 5mg daily
SH Local construction contractor. Drinks alcohol 1-2 times/week, “dips
tobacco” daily. Denies any illicit drug use.
FH Patient’s mother and father had hypertension
HEALTH Required for all SOAP notes: up to date on health
PROMOTION & maintenance/immunizations for her age.
MAINTENANC
E
ROS Constitutional Appears stated age
Head N/A
(put N/A in sections Eyes N/A
not completed day of
exam) Ears, Nose, Mouth, Throat N/A
Neck Denies any symptoms
Cardiovascular/Peripheral Denies chest pain or palpitations
Vascular
Respiratory Denies shortness of breath or
cough
Breast N/A
Gastrointestinal N/A
Genitourinary N/A
Musculoskeletal N/A
Integumentary N/A
Neurological N/A
Psychiatric (screening tools: Ex: N/A
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic N/A
Other N/A
, SOAP Note Unit 4 Name:
Typhon Encounter #:
NU 610:7D Comprehensive: Focused:
Herzing University
O: OBJECTIVE DATA
VITALS: HR: 75 bpm RR: 14 BP: 133/79 Temp: 98.9 F
breaths/min
SpO2%: 99% on Ht: 71 inches Wt: 205 lbs BMI: 28.6
room air
Age: 54 LMP: N/A PAIN: denies
any pain
PHYSICAL General Appearance appears stated age
EXAM Head Normocephalic
Eyes pupils PERRL
(Pertinent data ENT, Mouth No sinus tenderness; mucous
related to
presenting
membranes pink and dry,
problem or Neck No palpable masses,
visit type. Put adenopathy, or thyroid
N/A in sections enlargement.
not completed
day of exam)
Cardiovascular/Peripheral Vascular Regular heart rate and rhythm
without murmurs; no edema.
Respiratory Bilateral lung sounds clear
Breast N/A
Gastrointestinal Soft, non-tender, non-
distended; normoactive bowel
sounds. Umbilical hernia.
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal Strength 5/5 in all extremities.
Sensation intact to light and deep
touch; gait steady. Full shoulder
shrug against resistance; muscle
tone normal
Integumentary Skin warm and dry
Neurological Alert, oriented to self, place,
time, and situation.
Psychiatric N/A
Typhon Encounter #:
NU 610:7D Comprehensive: Focused:
Herzing University
S: SUBJECTIVE DATA
CC: Wellness check
HPI: A 54-year-old white male presents with a history of hypertension.
Hypertension is well controlled with amlodipine.
PMH: Hypertension
ALLERGIES NKDA
MEDICATIONS Amlodipine 5mg daily
SH Local construction contractor. Drinks alcohol 1-2 times/week, “dips
tobacco” daily. Denies any illicit drug use.
FH Patient’s mother and father had hypertension
HEALTH Required for all SOAP notes: up to date on health
PROMOTION & maintenance/immunizations for her age.
MAINTENANC
E
ROS Constitutional Appears stated age
Head N/A
(put N/A in sections Eyes N/A
not completed day of
exam) Ears, Nose, Mouth, Throat N/A
Neck Denies any symptoms
Cardiovascular/Peripheral Denies chest pain or palpitations
Vascular
Respiratory Denies shortness of breath or
cough
Breast N/A
Gastrointestinal N/A
Genitourinary N/A
Musculoskeletal N/A
Integumentary N/A
Neurological N/A
Psychiatric (screening tools: Ex: N/A
PHQ-9, MMSE, GAD-7)
Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic N/A
Other N/A
, SOAP Note Unit 4 Name:
Typhon Encounter #:
NU 610:7D Comprehensive: Focused:
Herzing University
O: OBJECTIVE DATA
VITALS: HR: 75 bpm RR: 14 BP: 133/79 Temp: 98.9 F
breaths/min
SpO2%: 99% on Ht: 71 inches Wt: 205 lbs BMI: 28.6
room air
Age: 54 LMP: N/A PAIN: denies
any pain
PHYSICAL General Appearance appears stated age
EXAM Head Normocephalic
Eyes pupils PERRL
(Pertinent data ENT, Mouth No sinus tenderness; mucous
related to
presenting
membranes pink and dry,
problem or Neck No palpable masses,
visit type. Put adenopathy, or thyroid
N/A in sections enlargement.
not completed
day of exam)
Cardiovascular/Peripheral Vascular Regular heart rate and rhythm
without murmurs; no edema.
Respiratory Bilateral lung sounds clear
Breast N/A
Gastrointestinal Soft, non-tender, non-
distended; normoactive bowel
sounds. Umbilical hernia.
Genitourinary Male
• External Exam N/A
• Internal Exam N/A
Genitourinary Female
• External Exam N/A
• Internal Exam N/A
Musculoskeletal Strength 5/5 in all extremities.
Sensation intact to light and deep
touch; gait steady. Full shoulder
shrug against resistance; muscle
tone normal
Integumentary Skin warm and dry
Neurological Alert, oriented to self, place,
time, and situation.
Psychiatric N/A
