Examples of a SOAP note #1
SUBJECTIVE
Chief complaint and history of present illness: 55-year-old female presents to the clinic for 6 month follow-up of hypertension and hyperlipidemia. Taking lisinopril 10mg daily and tolerating well. Home blood pressures 120/80. Tolerates atorvastatin 20mg daily. Reports improvement of low carb, low fat diet. Exercising 30 minutes 4 x week.
Past medical history: Hypertension and hyperlipidemia
Allergies: NKDA
Medications: Lisinopril 10 mg daily, atorvastatin 20mg daily
Review of systems:
CONSTITUTIONAL: No fever or chills. No weight loss or weight gain.
NEUROLOGICAL: No headaches.
EYES: No blurred or double vision.
CARDIOVASCULAR: No chest pain, shortness of breath, or palpitations. No peripheral edema.
RESPIRATORY: Denies shortness of breath or difficulty breathing. Denies cough.
GASTROINTESTINAL: Denies abdominal pain. No nausea or vomiting. Denies diarrhea or constipation.
MUSCULOSKELETAL: No joint or muscle pain. Denies swelling or redness of joints.
INTEGUMENTARY: No rash or itching. Denies wounds or lesions.
OBJECTIVE
Vital signs– Temp: 98.1 F, HR 65 bpm, BP 118/76, RR 18 resp/min, O2 sat 98% on room air
Exam:
CONSTITUTIONAL: This is a well-developed, well-nourished, adult male. No acute distress.
NEUROLOGICAL: Patient alert, orientated, memory intact.
LUNGS: Respirations even and unlabored, chest expansion symmetrical. Lung sounds clear in all lobes, no wheezing, crackles, or adventitious breath sounds.
HEART: Rate and rhythm regular. No cardiac murmur, click, or rub noted.
ABDOMEN: Soft, nontender. Bowel sounds active in all four quadrants.
MUSCULOSKELETAL/EXTREMITIES: Extremities are intact, no redness or edema noted of upper or lower extremity.
INTEGUMENTARY: Skin pink, dry, warm to touch. No rash, wounds, lesions noted on visible skin.
PSYCHOSOCIAL: Calm and cooperative, interacts appropriately with staff.
Diagnostic test:
Fasting lipid panel: Total cholesterol 160, triglycerides 130, HDL 60, LDL 80
ASSESSMENT:
Essential hypertension- controlled
Hyperlipidemia- controlled
PLAN:
Lipid panel stable. Blood pressure at goal. Refills of lisinopril 10mg daily and atorvastatin 20mg daily sent to Pharm Pharmacy. We discussed DASH diet and importance of exercise for management of HTN and hyperlipidemia. Follow-up in 6 months or sooner if needed. Patient verbalizes understanding regarding plan of care and all questions answered.