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- NSG6440
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- South University Online
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CONPH NSG6340/NSG6440 Subjective, Objective, Assessment, Plan (SOAP) NotesStudent Name: Lorie Sullivan Course: NSG6998
Patient Name: (Initials ONLY) T.M. Date: 7/24/2024 Time: 1053
Ethnicity: African American Age: 54 Sex: Male
SUBJECTIVE (must complete this section)
CC: Right knee pain x 2 days. Needs refill on zyrtec
HPI: 54-year-old African American Male presents to clinic with complaint of Right knee that has gotten worse the last 2
days. C/O Sharp and burning pain in medial and lateral knee. Does not radiate. Pain is not constant but is worse when
standing prolonged periods of time. Denies injury. States about 15 years ago he was running and heard a “Pop but never
seen anyone or got it treated.” Since then, he has episodic knee pain which is worse with activity and has some mild
swelling. Rates pain 5/10. He did take OTC Tylenol 500 mg 1 tablet every 4 hours for pain and Ibuprofen 400 mg 1 every
4-6 hours for swelling and pain. Has help some with mild relief.
Medications: Tylenol 500 mg 1 tablet by mouth every 4 hours for pain. Ibuprofen 400 mg 1 tablet by mouth every 4-6
hours for pain. Atorvastatin 20 mg 1 tablet by mouth for cholesterol. Viagra 100 mg ½-1 tablet my mouth once daily for
erectile dysfunction. Benicar HCT 20-12.5 mg 1 tablet by mouth once daily for hypertension. Cetirizine HCN 10 mg 1
tablet by mouth for allergies.
Previous Medical History: Hypertension, Hyperlipidemia, seasonal allergies, Erectile dysfunction
Allergies: No Known Drug Allergies
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, Hyperlipidemia, seasonal allergies, erectile dysfunction
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Hypertension, Asthma
MGM: Hypertension
MGF: Osteoarthritis
F: Glaucoma, BPH
PGM: Hypothyroidism
PGF: Prostate Cancer
Social History: Denies smoking, alcohol, illicit drugs. Flu Vaccine 12/2023.
REVIEW OF SYSTEMS (must complete this section)
General: Alert and oriented x 4, No weight loss, fever, Cardiovascular: No dyspnea, chest pain
chills, weigh loss or weight gain
Skin: No rash, lesions or tumors Respiratory: No cough, sputum production or shortness of
breath
Eyes: No visual disturbance, no eye discharge Gastrointestinal: No abdominal pain, vomiting, diarrhea, or
constipation. Nausea x 1 day
Ears: No ear pain or drainage Genitourinary/Gynecological: No frequent urination,
micturition. Bowel movement today.
Nose/Mouth/Throat: No cough, congestion, or nasal Musculoskeletal: Right knee pain medial and lateral, mild
drainage edema and warmth noted over patellar region.
Breast: No tenderness or abnormal mass Neurological: No tremors, weakness, no abnormal gait
Heme/Lymph/Endo: No bruising, bleeding, or swollen Psychiatric: No depression, anxiety, or insomnia
glands
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: 252 lbs Height: 73 in BMI: 32.24 BP: Temp: 98.4 Pulse: 91 Resp: 20
128/89
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