SOAP Notes on Neurofibroma, Dibetes Mellitus, and Seborrehic kertosis

Comprehensive SOAP Exemplar
Purpose: 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: _______
SUBJECTIVE DATA:
Chief Complaint (CC): Coughing up phlegm and fever
History of Present Illness (HPI): Patient X is a 40-year-old Caucasian female who presents today with an isolated, flesh-colored, and pedunculated skin lesion around armpit. She reported that although there is an absence of any ‘unusual feeling’ in and around the lesion, the sight of such “makes its bothersome for her”. She showed photos taken 2 weeks ago, after she went to the beach, where the lesion was still absent. Patient also reported that in the past week, she urinates more frequently and even had yeast infection just 3 days prior the checkup. She had associated symptoms such as fatigue whenever she walks for around 10 minutes. She noted that in order to relieve her fatigue, she has been consuming herbal tea, which she believes will “help her rejuvenate her strength and make her urination cycle regular”. She also rated the severity of her discomfort in doing menial tasks (brought about by fatigue) at 5/10.
Medications:
Over-the-counter Ibuprofen – 1 per day every after lunch
Chamomile Tea – 2 cups in the day and 1 cup in the night before sleeping
Miconazole – 2 times a day
Omeprazole – once every after meal
Allergies:
Banana, Peanuts, and Soy
Past Medical History (PMH):
1.) Hypertension – controlled through medications
3.) Gastroesophageal reflux (GERD) – quiet, on Omeprazole spray
Past Surgical History (PSH):
Appendectomy 2003
Sexual/Reproductive History:
Heterosexual
Regularly menstruating – 28 Day cycle; last menstruation 3 days ago
Personal/Social History:
Regular smoker = smokes 6 sticks of cigarettes each day x 10 years
denied illicit drug use
casual drinker = once or twice every week;
She eats five times a day = 3 meals and 2 snacks; no dietary program
Minimal physical activity = Patient is sitting for more than 8 hours per day
Immunization History:
Immunizations are not up to date. Patient received Pneumococcal vaccine 13 years ago while her influenza vaccine was received 9 years ago. No vaccination for HPV virus.
Significant Family History:
One sister, one brother – Sister is at age 32, while brother is aged 45. Mother is deceased at 63, due to cardiac arrest. Father is also deceased due to diabetes. Patient has two healthy daughters, no husband.
Lifestyle:
Patient is working at the Bank for 15 years. Divorced with two husbands, and is singly supporting her two kids. She is also a college graduate and owns the home where she and her family are living in.
Patient’s lifestyle is not too active. She has been obese since college and hasn’t taken adopted any form of exercise. Patient has medical insurance for her and her daughters. She does not have any other relatives left, but she lives in a community where the neighbors and tightly close with one another.
Review of Systems:
Ge...