CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Course: NSG6020_A-Advanced
Name: Health &Physical
Assessment
Patient K.T. Time: 06:29 pm
Name
(Initials
ONLY):
Date: 02/06/26 Sex: male
Age: 62 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I’m struggling with red, itchy, flaky patches on my elbows and
hairline that won’t resolve and affect how I feel about myself.”
HPI: Patient K.T. is a 62-year-old male presenting with a five-month
history of persistent dry, red, scaly patches on his scalp and
bilateral elbows. The symptoms started approximately five months
ago and have continued since then, with intermittent flares. The
lesions are described as pruritic, erythematous, dry, and scaly,
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
accompanied by flaking and irritation. The patient notes that his
symptoms may worsen during the period of increased emotional
stress, particularly due to his son’s recent divorce. He has tried an
over-the-counter moisturizer, which offered only minimal relief,
resulting in a slight improvement in dryness but no significant
change in the rash or itching. Symptoms occur daily and can
worsen episodically. The patient rates his itching as moderate and
expresses psychosocial distress, including feelings of
embarrassment and shame related to the appearance and itching of
the lesions. He denies having a fever, experiencing joint pain, or
having any recent infections. Additionally, he does not report using
any new shampoo, body wash, or other skincare products.
Medications: Lisinopril 20 mg PO 1 tablet once a day lifelong for hypertension
Levodopa 25 mg PO 3 times daily lifelong for Parkinson disease
Previous Medical - COVID-19 (2020, 2023)
History:
- Asthma
Allergies: NKA
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Parkinson disease
- Obesity
- History of asthma
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider two times a year, except when experiencing flu symptoms
or chronic disease exacerbation. He has undergone surgeries in the
past:
- Tonsillectomy (1971)
- Left knee replacement (2018)
FAMILY HISTORY (must complete this section)
M (Mother): History of cancer
MGM History of hypertension
(Maternal
Student Course: NSG6020_A-Advanced
Name: Health &Physical
Assessment
Patient K.T. Time: 06:29 pm
Name
(Initials
ONLY):
Date: 02/06/26 Sex: male
Age: 62 years old Ethnicity: white
SUBJECTIVE (must complete this section)
CC: “I’m struggling with red, itchy, flaky patches on my elbows and
hairline that won’t resolve and affect how I feel about myself.”
HPI: Patient K.T. is a 62-year-old male presenting with a five-month
history of persistent dry, red, scaly patches on his scalp and
bilateral elbows. The symptoms started approximately five months
ago and have continued since then, with intermittent flares. The
lesions are described as pruritic, erythematous, dry, and scaly,
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
accompanied by flaking and irritation. The patient notes that his
symptoms may worsen during the period of increased emotional
stress, particularly due to his son’s recent divorce. He has tried an
over-the-counter moisturizer, which offered only minimal relief,
resulting in a slight improvement in dryness but no significant
change in the rash or itching. Symptoms occur daily and can
worsen episodically. The patient rates his itching as moderate and
expresses psychosocial distress, including feelings of
embarrassment and shame related to the appearance and itching of
the lesions. He denies having a fever, experiencing joint pain, or
having any recent infections. Additionally, he does not report using
any new shampoo, body wash, or other skincare products.
Medications: Lisinopril 20 mg PO 1 tablet once a day lifelong for hypertension
Levodopa 25 mg PO 3 times daily lifelong for Parkinson disease
Previous Medical - COVID-19 (2020, 2023)
History:
- Asthma
Allergies: NKA
, CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes
Medication The patient reports no known adverse reactions or allergies to any
Intolerances:
medications.
Chronic - Hypertension
Illnesses/Major
Traumas: - Parkinson disease
- Obesity
- History of asthma
Hospitalizations/ The patient receives regular medical care, visiting his primary care
Surgeries:
provider two times a year, except when experiencing flu symptoms
or chronic disease exacerbation. He has undergone surgeries in the
past:
- Tonsillectomy (1971)
- Left knee replacement (2018)
FAMILY HISTORY (must complete this section)
M (Mother): History of cancer
MGM History of hypertension
(Maternal
