Eddie Myers SOAP Exemplar
The purpose of Eddie Myers SOAP Exemplar is to demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.
Patient Initials: _______ Age: _______ Gender: _______
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Eddie Myers SOAP Exemplar SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Eddie Myers is a 58-year-old African American male who presents today with a productive cough x 3 days, fever, muscle aches, and loss of taste and smell for the last three days. He reported that the “cold feels like it is descending into his chest and he can’t eat much”. The cough is nagging and productive. He brought in a few paper towels with expectorated phlegm – yellow/green in color. He has associated symptoms of dyspnea of exertion and fatigue. His Tmax was reported to be 100.3, last night. He has been taking Tylenol 325mg about every 6 hours and the fever breaks, but returns after the medication wears off. He rated the severity of her symptom discomfort at 8/10.
Medications:
1.) Norvasc 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Advair 500/50 Daily
4.) Singulair 10mg daily
5.) Over-the-counter Tylenol 325mg as needed
6.) Over-the-counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhinitis symptoms
Allergies:
Sulfa drugs – rash
Cipro-headache
Past Medical History (PMH):
1.) Asthma
2.) Hypertension
3.) Osteopenia
4.) Allergic rhinitis
5.) Prostate Cancer
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Prostatectomy 1986
Sexual/Reproductive History:
Heterosexual
Personal/Social History:
He has never smoked
Dipped tobacco for 25 years, no longer dipping
Denied ETOH or illicit drug use.
Immunization History:
Covid Vaccine #1 3/2/2021 #2 4/2/2021 Moderna
Influenza Vaccination 10/3/2020
PNV 9/18/2018
Tdap 8/22/2017
Shingles 3/22/2016
Significant Family History:
One sister – with diabetes, dx at age 65
One brother–with prostate CA, dx at age 62. He has 2 daughters, both in 30’s, healthy, and living in a nearby neighborhood.
Lifestyle:
He works FT as Xray Tech; widowed x 8 years; lives in the city, moderate crime area, with good public transportation. He is a college grad, owns his home, and is financially stable.
He has a primary care nurse practitioner provider and goes for annual and routine care twice annually and as needed for episodic care. He has medical insurance but often asks for drug samples for cost savings. He has a healthy diet and eating pattern. There are resources and community groups in his area at the senior center but he does not attend. He enjoys golf and walking. He has a good support system composed of family and friends.
Review of Systems:
General: + fatigue since the illness started; + fever, no chills or night sweats; no recent weight gains or losses of significance.
HEENT: no changes in vision or hearing; he does wear glasses and his last eye exam was 6 months ago. He reported no history of glaucoma, diplopia, floaters, excessive tearing, or photophobia. He does have bilateral small cataracts that are being followed by his ophthalmologist. He has had no recent ear infections, tinnitus, or discharge from the ears. He reported no sense of smell. He has not had any episodes of epistaxis. He does not have a history of nasal polyps or a recent sinus infection. He has a history of allergic rhinitis that is seasonal. His last dental exam was on 1/2020. He denied ulceration, lesions, gingivitis, and gum bleeding, and has no dental appliances. He has had no difficulty chewing or swallowing.
Neck: Denies pain, injury, or history of disc disease or compression.
Breasts: Denies history of lesions, masses, or rashes.
Respiratory: + cough and sputum production; denied hemoptysis, no difficulty breathing at rest; + dyspnea on exertion; he has a history of asthma and community-acquired pneumonia in 2015. The last PPD was in 2015. Last CXR – 1 month ago.
CV: denies chest discomfort, palpitations, and history of murmur; no history of arrhythmias, orthopnea, paroxysmal nocturnal dyspnea, edema, or claudication. The date of the last ECG/cardiac workup is unknown by the patient.
GI: denies nausea or vomiting, reflux controlled, Denies pain, no changes in bowel/bladder pattern. He uses fiber as a daily laxative to prevent constipation.
GU: denies change in her urinary pattern, dysuria, or incontinence. He is heterosexual. No denies history of STDs or HPV. He is sexually active with his long-time girlfriend of 4 years.
MS: he denies arthralgia/myalgia, no arthritis, gout, or limitation in her range of motion by the report. denies a history of trauma or fractures.
Psych: denies history of anxiety or depression. No sleep disturbance, delusions, or mental health history. He denied suicidal/homicidal history.
Neuro: denies syncopal episodes or dizziness, no paresthesia, or headaches. denies change in memory or thinking patterns; no twitches or abnormal movements; denies history of gait disturbance or problems with coordination. denies falls or seizure history.
Integument/Heme/Lymph: denies rashes, itching, or bruising. She uses lotion to prevent dry skin. He denies a history of skin cancer or lesion removal. She has no bleeding disorders, clotting difficulties, or history of transfusions.
Endocrine: He denies polyuria/polyphagia/polydipsia. Denies fatigue, heat or cold intolerances, shedding of hair, unintentional weight gain, or weight loss.
Allergic/Immunologic: He has a history of allergic rhinitis, but no known immune deficiencies. His last HIV test was 2 years ago.
Eddie Myers SOAP Exemplar OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 144/98, left arm, sitting, regular cuff; P 90 and regular; T 99.9 Orally; RR 16; non-labored; Wt: 221 lbs; Ht: 5’5; BMI 36.78
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd, or thyromegaly
Chest/Lungs: Lungs pos wheezing, pos for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial
ABD: nabs x 4, no organomegaly; mild suprapubic tenderness – diffuse – no rebound
Genital/Rectal: pt declined this exam
Musculoskeletal: symmetric muscle development – some age-related atrophy; muscle strengths 5/5 in all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no palpable nodes
Diagnostics/Lab Tests and Results:
CBC – WBC 15,000 with + left shift
SAO2 – 98%
Covid PCR-neg
Influenza- neg
Radiology:
CXR – cardiomegaly with air trapping and increased AP diameter
ECG
Normal sinus rhythm
Spirometry- FEV1 65%
Assessment:
Differential Diagnosis (DDx):
1.) Asthmatic exacerbation, moderate
2.) Pulmonary Embolism
3.) Lung Cancer
Primary Diagnoses:
1.) Asthmatic Exacerbation, moderate
PLAN: [This section is not required for the assignments in this course, but will be required for future courses.