SOAP note Identification\ Problem Recognition Patient initial Nationality Age Sex Source of information Problem Statement SUBJECTIVE DATA HPI PMH Surgical History/Hospitalization Family History Social History Allergies MEDS. Immunization ROS HEENT RESP. CV GI\GU MSK SKIN Mental OBJECTIVE DATA & PHYSICAL ASSESSMENT V\S General Appearance HEENT Neuro. CV RESP. GI \ GU Skin Musculoskeletal Mental DIAGNOSTIC TESTS Final Diagnosis DIFFRENTIAL DIAGNOSIS Diagnosis Positive findings Negative findings Plan Nonpharmacological treatment Pharmacological Treatment DRUG General Considerations Surgery/Other Procedures Follow Up Education Referral Learning Resources 1 SOAP note Identification\ Problem Recognition Patient initial Nationality Age Sex Source of information Problem Statement SUBJECTIVE DATA HPI PMH Surgical History/Hospitalization Family History Social History Allergies MEDS. Immunization ROS HEENT RESP. CV GI\GU MSK SKIN Mental OBJECTIVE DATA & PHYSICAL ASSESSMENT V\S General Appearance HEENT Neuro. CV RESP. GI \ GU Skin Musculoskeletal Mental DIAGNOSTIC TESTS Final Diagnosis DIFFRENTIAL DIAGNOSIS Diagnosis Positive findings Negative findings Plan Nonpharmacological treatment Pharmacological Treatment DRUG General Considerations Surgery/Other Procedures Follow Up Education Referral Learning Resources 1 Identification\ Problem Recognition Patient initial C.K Nationality Saudi Age 28 years Sex Male Source of information Patient Problem Statement I have been experiencing burning chest pains, regurgitation, and acid tastes in the mouth. This happens mostly after taking a meal or snack and it makes me uncomfortable. HPI When examined, the patient said that he had been experiencing severe heartburns for the last three weeks. He also suffered from hernia where stomach contents would reflux and move upwards to the oesophagus. Two weeks ago, he could not control the situation and he started experiencing coughs and vomiting. The patient also said that he was experiencing acid irritations along the windpipe. Other symptoms shown by the patient include hoarseness, sore throat, throat lumps, and chronic sinusitis. PMH The patient had been experiencing heartburns for the last one year. He had relied on anti-acids all along and the situation was controlled for some time but it has reappeared once again. Surgical History/Hospitalization The patient has never been to surgery and has never been hospitalized. He usually buys over the counter drugs. Family History Only his sister ex.

1. SOAP note
Identification Problem Recognition
Patient initial
Nationality
Age
Sex
Source of information
Problem Statement
SUBJECTIVE DATA

2. HPI
PMH
Surgical History/Hospitalization
Family History
Social History
Allergies
MEDS.
Immunization

3. ROS
HEENT
RESP.
CV
GIGU
MSK
SKIN

4. Mental
OBJECTIVE DATA
&
PHYSICAL ASSESSMENT
VS
General Appearance
HEENT
Neuro.
CV
RESP.

5. GI GU
Skin
Musculoskeletal
Mental
DIAGNOSTIC TESTS
Final Diagnosis
DIFFRENTIAL DIAGNOSIS
Diagnosis
Positive findings
Negative findings

6. Plan
Nonpharmacological treatment

7. Pharmacological Treatment
DRUG
General Considerations
Surgery/Other Procedures
Follow Up
Education

8. Referral
Learning Resources
1
SOAP note

9. Identification Problem Recognition
Patient initial
Nationality
Age
Sex
Source of information
Problem Statement
SUBJECTIVE DATA
HPI

10. PMH
Surgical History/Hospitalization
Family History
Social History
Allergies
MEDS.
Immunization

11. ROS
HEENT
RESP.
CV
GIGU
MSK
SKIN
Mental

12. OBJECTIVE DATA
&
PHYSICAL ASSESSMENT
VS
General Appearance
HEENT
Neuro.
CV
RESP.

13. GI GU
Skin
Musculoskeletal
Mental
DIAGNOSTIC TESTS
Final Diagnosis
DIFFRENTIAL DIAGNOSIS
Diagnosis
Positive findings
Negative findings

14. Plan
Nonpharmacological treatment

15. Pharmacological Treatment
DRUG
General Considerations
Surgery/Other Procedures
Follow Up
Education

16. Referral
Learning Resources
1

17. Identification Problem Recognition
Patient initial
C.K
Nationality
Saudi
Age
28 years
Sex
Male
Source of information
Patient
Problem Statement
I have been experiencing burning chest pains, regurgitation, and
acid tastes in the mouth. This happens mostly after taking a
meal or snack and it makes me uncomfortable.
HPI
When examined, the patient said that he had been experiencing
severe heartburns for the last three weeks. He also suffered
from hernia where stomach contents would reflux and move
upwards to the oesophagus. Two weeks ago, he could not
control the situation and he started experiencing coughs and
vomiting. The patient also said that he was experiencing acid
irritations along the windpipe. Other symptoms shown by the
patient include hoarseness, sore throat, throat lumps, and
chronic sinusitis.

18. PMH
The patient had been experiencing heartburns for the last one
year. He had relied on anti-acids all along and the situation was
controlled for some time but it has reappeared once again.
Surgical History/Hospitalization
The patient has never been to surgery and has never been
hospitalized. He usually buys over the counter drugs.
Family History
Only his sister experienced GERD when she was pregnant but
she was okay after conceiving. There is no concrete evidence of
other family members suffering from GERD.
Social History
The patient is a Muslim. He is a mechanical and production
engineer by profession. He is a smoker but does not sniff
tobacco.
Allergies
The patient has no allergy to food or any drugs. He sometimes
experiences nasal blockage when exposed to dust or cold. He
takes asthma spray to take care of the situation.
MEDS.
The patient is on omeprazole 40 mg and Antacid 5mg daily. The
meds are taken orally. The patient has also changed feeding
lifestyle by avoiding acidic foods.
Immunization
The patient has received the mandatory childhood and adulthood
immunizations since he was a child. He has received Whooping
cough and tetanus immunization.

19. ROS
HEENT
Head: the patient has been experiencing severe headaches after
hernia.
Eyes: The patient experiences dizziness and eye pain when
exposed to direct sunlight. He started wearing glasses after he
started having blurred vision.
Ears: The patient has no ear problems.
Nose: no nosebleeds but there are nasal itching and blockage
when exposed to dust.
Throat: the patient has difficulty in swallowing. He also has
nausea and vomits severally especially after eating or drinking.
The patient cannot swallow heavy meals.
RESP.
The patient has dry cough The patient has a normal breath.
CV
The patient has severe chest pains.
GIGU

20. The patient has nausea and vomiting. He has a normal bowel
movement and there is no pain reported after long and short
calls.
MSK
The paint has no joint pains.
SKIN
The patient has dry skin with rashes
Mental
He has never had psychiatric conditions. He is not confused and
he speaks fluently. Can interpret idea and communicate
effectively.
OBJECTIVE DATA
&
PHYSICAL ASSESSMENT
VS
Respiration rate: 21 breaths per minute.
Blood Pressure: 120/80mmHg
Temp. 37.0 C .
Ht: 176 cm.
Heart rate: 100 b/m.

21. Wt: 82kg.
BMI = 26.5.
General Appearance
The patient seems to be moody and exhausted.
HEENT
H: The head is okay, no hair loss.
Eyes: The eyelids are normal, no scars or discharge.
Ears. The patient does not have vertigo or any hearing
impairment. Also, no discharge.
Nose: he has a running nose. Claims that he was exposed to
dusty conditions while at work.
Throat: the patient has larynx inflammation and swollen lymph
nodes.
Neuro.
The nerve system is okay, no nerve damage.
CV
The pulse rate of the patient is 100 b/m and the blood pressure
is 120/80 mmHg.
RESP.
The patient has a dry cough and wheezes a lot at night or after
jogging or performing a small task.
GI GU

22. Although there are chest pains, X-ray shows that chest muscles
are okay, do damaged ligaments. The pharynx is reddish and
swollen. There are no abdominals scars and the bowel
movement is normal.
Skin
The skin is dry and pale with rashes.
Musculoskeletal
There are no fractures.
Mental
The patient is moody and worried.
DIAGNOSTIC TESTS
· Oesophageal pH Test.
· Acid reflux test.
· upper endoscopy test.
· Esophageal manometry test.
· PPI therapy.
· Ambulatory acid probe test.
Diagnostic test results:
· Oesophageal pH Test- (2.0)-highly acidic
· Acid reflux test-pictures of the oesophagus show that the
oesophagus and stomach walls have ulcers.
· Upper endoscopy test is carried out to evaluate the
effectiveness of the ambulatory acid probe test.

23. · Esophageal manometry test- particles of food were found on
the sphincter.
· PPI therapy- the oesophagus was found to be highly acidic.
· Ambulatory acid probe test- it was noted that the patient
alternating levels of acid reflux ranging 2.0-4.0.
Final Diagnosis
Gastroesophageal Reflux Disease (GERD).
DIFFRENTIAL DIAGNOSIS
Diagnosis
Positive findings
Negative findings
Coronary
Artery Disease (CAD).
Cardiac etiology must be done before doing a diagnosis for
GERD patients with severe chest pains.
The test may differ; ECG can show Q or ST changes.
Oesophageal disorder.
Severe chest pains are always substernal due to exertion and can
be relieved by having some rest.
Stress testing may subject the patient to abnormal/irrelevant
tests.
Peptic ulcer disease.

24. Burning pain/sensation in the epigastrium, may occur after
meals. The patient is uncomfortable at night and it can be
controlled by taking some food or antacids.
Endoscopy shows the presence of ulcers. The test for
Helicobacter pylori is positive but not diagnostic.
Eosinophilic esophagitis
Esophagitis,eosinophilic, and features of GERD overlap.
Symptoms are not detected at older ages.
Endoscopy shows linear furrows, exudates, white plaques, and
oesophageal rings at the base of the oesophagus. The number of
eosinophil is higher than that of typical GERD. It can be more
than 15 in every sampled oesophageal tissue.
Proton pump inhibitor.
This is done when the patient has oesophageal problems but he
demonstrates proton-pump inhibition symptoms.
Therapeutic response is done to PPI. PPI dose should be similar
to those of erosive esophagitis with duration of more than 8
weeks. There must be a follow-up after biopsy and endoscopy.
Plan
Nonpharmacological treatment
One of the causes of GERD is excessive eating and smoking.
The patient should take action and revise his diet by taking light

25. meals for easy digestion and also taking a lot of water (Pallati
et al, 2014 p. 505).
Pharmacological Treatment
DRUG
General Considerations
GERD medications:
Omeprazole 500mg daily.
Antacid 5mg daily.
receptor antagonists 5mg twice a day .
Histamine-2 (H2) 500mg daily.
The total medication time is about 14 days in total.
It cannot exceed or go below that.
Adrenergic agonists may lead to nausea and oversleeping and
therefore the patient should take caution.
Surgery/Other Procedures
When medications do not comply, surgery can be done to reduce
size of hernia. Surgery is not an option for this patient because
it requires a stronger evidence and recommendation.
Follow Up
The patient is advised to take full medication for 3 months. He
should also book an appointment with a doctor after every one
week to go for check-up.

26. Education
-The patient should first quit smoking. The oesophageal
sensations and irritations may be due to cigarette smoke. Also,
the patient has dust allergy and should avoid smoky areas by all
means (Tan et al, 2016 p. 5).
-The patient should be advised on the best diet to reduce the
level of acidity along the oesophagus. He should avoid acidic
foods like peppermint, chocolate, tomatoes, spicy foods,
caffeine, citrus fruits, and onions.
-The patient should drink a lot of water to avoid dehydration
due to vomiting.
-Stomach PH should be monitored, also check presence of
ulcers.
-Lifestyle modifications are very important while trying to
eliminate GERD symptoms. Patients are advised to undergo
pharmacologic therapy.
- Depending on the symptoms and level of acidity. Severe
GERD is handled by PPI therapy to ensure a faster recovery
(Pallati et al, 2014 p. 505).
-Also, another measure is to maintain a healthy weight.
GERD is caused by overweight and GERD patients should
control their weights.
-Also, one should avoid lying down after meals and avoid
eating late at night (Ganz et al, 2013 p. 722).
-It is also advisable to raise the bed on the head side and avoid
wearing tight fitting clothes.
-Not all GERD medicines are good since some may worsen the

27. situation. Such drugs include theophylline, calcium blockers,
and anticholinergic drugs. Also, patients should avoid anti-
inflammatory drugs like ibuprofen and asprin unless
recommended by a health provider.
Referral
Refer to dietician.
Learning Resources
Ganz, R.A., Peters, J.H., Horgan, S., Bemelman, W.A., Dunst,
C.M., Edmundowicz, S.A., Lipham, J.C., Luketich, J.D.,
Melvin, W.S., Oelschlager, B.K. and Schlack-Haerer, S.C.,
2013. Esophageal sphincter device for gastroesophageal reflux
disease. New England Journal of Medicine, 368(8), pp.719-
727.
Kavitt, R.T. and Vaezi, M.F., 2016. Gastroesophageal Reflux
Disease. Practical Gastroenterology and Hepatology Board
Review Toolkit, pp.85-90.
Khan, S. and Orenstein, S.R., 2018. Gastroesophageal reflux
disease. Current and Future Developments in Surgery
Volume 1: Oesophago-gastric Surgery, 1, p.189. retrieved
from: https://medbroadcast.com/channel/digestive-
health/related-conditions/gerd-gastroesophageal-reflux-disease
Pallati, P.K., Shaligram, A., Shostrom, V.K., Oleynikov, D.,
McBride, C.L. and Goede, M.R., 2014. Improvement in
gastroesophageal reflux disease symptoms after various
bariatric procedures: review of the Bariatric Outcomes

28. Longitudinal Database. Surgery for Obesity and Related
Diseases, 10(3), pp.502-507. Retrieved from:
https://www.webmd.com/heartburn-
gerd/guide/heartburn_gerd_treatment_care
Tan, V.P.Y., Wong, B.C., Wong, W.M., Leung, W.K., Tong, D.,
Yuen, M.F. and Fass, R., 2016. Gastroesophageal Reflux
Disease. Journal of clinical gastroenterology, 50(1), pp.1-7.
Retrieved from:
https://www.webmd.com/heartburngerd/guide/heartburn_ge
rd_diagnosis_tests
Sheet1Advanced Nurse Practice Nurse Schedule-Monthly
Date Requested On: 4 November 2018Time Period: 28/10/2018-
22/11/2018
Executed on:Printed for: Student Development Unit
Updated 4 November 20185-
AugSMTWTFSSMTWTFSSMTWTFSSMTWTFSSMTWTTOTA
LHOURSPOS28293031123456789101112131415161718192021
222324252627282930UNIT1Pia PadillaNourah
AlshenaifyOPDAPNADMADMADMADMADMADMADMADM
ADMADMADMADMADMADM141352Pia PadillaNajla Dbyan
AlshammariOPDAPNADMADMADMADMADMADMADMAD
MADMADMADMADMADMADMADM151353Jerelyn
DongalloShamsah Farhan
AlanaziOPDAPNADMADMADMADMADMADMADMADMAD
MADMADMADMADMADMADM151354Jerelyn DongalloDalal
Abdullah
AlnahdiOPDAPNADMADMADMADMADMADMADMADMAD
MADMADMADMADMADMADM151355Ms Jennifer
MoodleyNorah Saad

29. AlqaydhiMEDICALAPNMMMMMMMMMMMMMMM151356A
shraf ManalasJamila Al
ZahraniEDAPNcccMMMMMMMMMMMm151357Ashraf
ManalasHalim Mahdi
OtenEDAPNMMMMMMMmMMMmMMm151358Roma
MananganJohara F.
AlharbiEDAPNMMMmMmMMMMMMMMm151359Kathleen
TanNohrah A
AlnahdiEDAPNMMMMmMMMMMmMMMm1513510?Salwa
Yayya
AlwaddahEDAPNMMMMMMMmMMMMMMm1513511Legend
: PRECEPTOR ON DUTYRABIA KHANRABIA KHAN,
NMMS. SABARINA JUMAT, DONcConferencePrepared
By:Reviewed By:Approved By:Mnew duties to make up hours√-
updated dutyM-06h45-16h00ADM-0730-1630APN - Advanced
Practice Nursing student
General Feedback:
· Make sure all pseudo names.
· Patient primarily needs to be the source of the information.
For very young children then a parent or guardian but not only
the clinical files.
· Subjective information is when you the clinician asks the
patient questions to get a clinical history regarding the review
of systems. You don’t have to write the exact questions you
asked we just need to know
the clinical history.
For example:
Eyes: No history of blurred Vision, double Vision, eye pain or
eye discharge. No history of foreign body. Never worked
grinding metal. Does not wear glasses or contacts.
Ears: No history of hearing problems, ear pain, discharge from
ear.

30. Neurological: No history of headache, dizziness, numbness,
seizure, tremor, loss of balance.
· Objective information is the information you as the examining
clinician finds during your head to toe detailed assessment.
For example:
Eyes: Conjunctiva red bilaterally with white sclera. Pupils are
equal, round, and reactive to light and accommodation size
4>2mm. No oedema of eyelids, no blepharitis noted bilaterally.
Extra Occular ROM normal bilaterally. Visual acuity 6/9+1 (R)
eye & 6/9+3 (L) eye. Near vision unremarkable in both eyes.
Red reflex present bilaterally. No strabismus, no nystagmus.
Fundoscopic exam normal, vessels intact, optic disc with clear
margins, no hemorrhages or exudates, no arteriolar narrowing.
Ears: Acuity good to whispered voice. Tympanic membranes
intact with good cone of light. Mild wax noted. Weber =
midline. Rinne test = AC > BC.
Neuro: Patient alert and orientated to person, time and place.
GCS 15/15. CN I-XII intact. Motor: Good muscle bulk and tone.
Strength 5/5 throughout. Cerebellar: Rapid alternating
movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→S)
intact. Fluid Gait with normal base. Romberg: maintains balance
with eyes closed. No pronator drift noted. Sensory: Pain & light
touch = normal. Position sense, stereognosia, Graphesthesia and
Extinction = Normal. Vibration intact. Reflexes: 2+ and
symmetric with plantar reflexes down going.
· You need to use equipment such as tuning forks,
ophthalmoscopes, otoscopes etc… if the department doesn’t
have it maybe buy your own.
· Drug generic names
· Drug dosage correct.
· For female patients menstrual cycle is important to document.
· Abbreviations – first use name then abbreviate, recognized

31. abbreviations.
· Length of SOAP notes some 1 page others 11pages
· Diagnostic tests need justification sometimes the risk out-
weights the benefit as well as been a cost to the health service
and the patient.
· Results of test – no need saying bloods/xray etc… and not
saying what the results were.
· Please use same font throughout the SOAP note.
· Please check that sure if the patient is male then he.
Sometimes the notes can have both he and she even though the
patient is male. Same applies for a female patient.
· Please check information is correct read over before
submitting because one SOAP note said that the patient had a
caesarean section at 5 years old but I presumed the patient had
it five years ago.
· Differential Diagnosis should be a long list of every condition
associated with the system involved, please critically think your
differential diagnosis and justify your diagnosis.
· Plan of care needs to be the actual plan for your patient not
only what the text books say!
· References should be at the end and should be used to support
your diagnosis.
· Please check spellings prior to submission here are a few
examples of what was in the SOAP 1 & SOAP 2,
Denies – In notes were both Denise and Denis – these are two
names.
Warm – In notes it stated worm – this would then need to be
treated.
Sheet1Advanced Nurse Practice Nurse Schedule-Monthly
Date Requested On: 4 November 2018Time Period: 28/10/2018-
22/11/2018
Executed on:Printed for: Student Development Unit
Updated 4 November 20185-

32. AugSMTWTFSSMTWTFSSMTWTFSSMTWTFSSMTWTTOTA
LHOURSPOS28293031123456789101112131415161718192021
222324252627282930UNIT1Pia PadillaNourah
AlshenaifyOPDAPNADMADMADMADMADMADMADMADM
ADMADMADMADMADMADM141352Pia PadillaNajla Dbyan
AlshammariOPDAPNADMADMADMADMADMADMADMAD
MADMADMADMADMADMADMADM151353Jerelyn
DongalloShamsah Farhan
AlanaziOPDAPNADMADMADMADMADMADMADMADMAD
MADMADMADMADMADMADM151354Jerelyn DongalloDalal
Abdullah
AlnahdiOPDAPNADMADMADMADMADMADMADMADMAD
MADMADMADMADMADMADM151355Ms Jennifer
MoodleyNorah Saad
AlqaydhiMEDICALAPNMMMMMMMMMMMMMMM151356A
shraf ManalasJamila Al
ZahraniEDAPNcccMMMMMMMMMMMm151357Ashraf
ManalasHalim Mahdi
OtenEDAPNMMMMMMMmMMMmMMm151358Roma
MananganJohara F.
AlharbiEDAPNMMMmMmMMMMMMMMm151359Kathleen
TanNohrah A
AlnahdiEDAPNMMMMmMMMMMmMMMm1513510?Salwa
Yayya
AlwaddahEDAPNMMMMMMMmMMMMMMm1513511Legend
: PRECEPTOR ON DUTYRABIA KHANRABIA KHAN,
NMMS. SABARINA JUMAT, DONcConferencePrepared
By:Reviewed By:Approved By:Mnew duties to make up hours√-
updated dutyM-06h45-16h00ADM-0730-1630APN - Advanced
Practice Nursing student