This document serves as a comprehensive SOAP note exemplar aimed at guiding nurse practitioners in documenting patient assessments holistically. It details the case of a 65-year-old female patient presenting with respiratory symptoms, medical history, and relevant diagnostic findings. The SOAP format is highlighted for organizing subjective and objective data, assessments, and plans of care in clinical practice.

1. 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): Sara Jones is a 65 year old
Caucasian female who presents today with a productive cough x
3 weeks and fever for the last three days. She reported that the
“cold feels like it is descending into her chest”. The cough is
nagging and productive. She brought in a few paper towels with
expectorated phlegm – yellow/brown in color. She has
associated symptoms of dyspnea of exertion and fever. Her
Tmax was reported to be 102.4, last night. She has been taking
Ibuprofen 400mg about every 6 hours and the fever breaks, but
returns after the medication wears off. She rated the severity of
her symptom discomfort at 4/10.
Medications:
1.) Lisinopril 10mg daily
2.) Combivent 2 puffs every 6 hours as needed
3.) Serovent daily
4.) Salmeterol daily
5.) Over the counter Ibuprofen 200mg -2 PO as needed
6.) Over the counter Benefiber
7.) Flonase 1 spray each night as needed for allergic rhini tis

2. symptoms
Allergies:
Sulfa drugs - rash
Past Medical History (PMH):
1.) Emphysema with recent exacerbation 1 month ago – deferred
admission – RX’d with outpatient antibiotics and an hand held
nebulizer treatments.
2.) Hypertension – well controlled
3.) Gastroesophageal reflux (GERD) – quiet on no medication
4.) Osteopenia
5.) Allergic rhinitis
Past Surgical History (PSH):
1.) Cholecystectomy 1994
2.) Total abdominal hysterectomy (TAH) 1998
Sexual/Reproductive History:
Heterosexual
G1P1A0
Non-menstrating – TAH 1998
Personal/Social History:
She has smoked 2 packs of cigarettes daily x 30 years; denied
ETOH or illicit drug use.
Immunization History:
Her immunizations are up to date. She received the influenza
vaccine last November and the Pneumococcal vaccine at the
same time.
Significant Family History:
Two brothers – one with diabetes, dx at age 65 and the other
with prostate CA, dx at age 62. She has 1 daughter, in her 50’s,
healthy, living in nearby neighborhood.

3. Lifestyle:
She is a retired; widowed x 8 years; lives in the city, moderate
crime area, with good public transportation. She college
graduate, owns her home and receives a pension of $50,000
annually – financially stable.
She has a primary care nurse practitioner provider and goes for
annual and routine care twice annually and as needed for
episodic care. She has medical insurance but often asks for drug
samples for cost savings. She has a healthy diet and eating
pattern. There are resources and community groups in her area
at the senior center and she attends regularly. She enjoys bingo.
She 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 of losses of significance.
HEENT: no changes in vision or hearing; she does wear glasses
and her last eye exam was 1 ½ years ago. She reported no
history of glaucoma, diplopia, floaters, excessive tearing or
photophobia. She does have bilateral small cataracts that are
being followed by her ophthalmologist. She has had no recent
ear infections, tinnitus, or discharge from the ears. She reported
her sense of smell is intact. She has not had any episodes of
epistaxis. She does not have a history of nasal polyps or r ecent
sinus infection. She has history of allergic rhinitis that is
seasonal. Her last dental exam was 3/2014. She denied
ulceration, lesions, gingivitis, gum bleeding, and has no dental
appliances. She has had no difficulty chewing or swallowing.
Neck: no pain, injury, or history of disc disease or compression.
Her last Bone Mineral density (BMD) test was 2013 and showed
mild osteopenia, she said.

4. Breasts: No reports of breast changes. No history of lesions,
masses or rashes. No history of abnormal mammograms.
Respiratory: + cough and sputum production (see HPI); denied
hemoptysis, no difficulty breathing at rest; + dyspnea on
exertion; she has history of COPD and community acquired
pneumonia 2012. Last PPD was 2013. Last CXR – 1 month ago.
CV: no chest discomfort, palpitations, history of murmur; no
history of arrhythmias, orthopnea, paroxysmal nocturnal
dyspnea, edema, or claudication. Date of last ECG/cardiac work
up is unknown by patient.
GI: No nausea or vomiting, reflux controlled, No abd pain, no
changes in bowel/bladder pattern. She uses fiber as a daily
laxative to prevent constipation.
GU: no change in her urinary pattern, dysuria, or incontinence.
She is heterosexual. She has had a total abd hysterectomy. No
history of STD’s or HPV. She has not been sexually active since
the death of her husband.
MS: she has no arthralgia/myalgia, no arthritis, gout or
limitation in her range of motion by report. No history of
trauma or fractures.
Psych: no history of anxiety or depression. No sleep
disturbance, delusions or mental health history. She denied
suicidal/homicidal history.
Neuro: no syncopal episodes or dizziness, no paresthesia, head
aches. No change in memory or thinking patterns; no twitches
or abnormal movements; no history of gait disturbance or
problems with coordination. No falls or seizure history.

5. Integument/Heme/Lymph: no rashes, itching, or bruising. She
uses lotion to prevent dry skin. She has no history of skin
cancer or lesion removal. She has no bleeding disorders,
clotting difficulties or history of transfusions.
Endocrine: no endocrine symptoms or hormone therapies.
Allergic/Immunologic: this has hx of allergic rhinitis, but no
known immune deficiencies. Her last HIV test was 10 years ago.
OBJECTIVE DATA
Physical Exam:
Vital signs: B/P 110/72, left arm, sitting, regular cuff; P 70 and
regular; T 98.3 Orally; RR 16; non-labored; Wt: 115 lbs; Ht:
5’2; BMI 21
General: A&O x3, NAD, appears mildly uncomfortable
HEENT: PERRLA, EOMI, oronasopharynx is clear
Neck: Carotids no bruit, jvd or tmegally
Chest/Lungs: CTA AP&L
Heart/Peripheral Vascular: RRR without murmur, rub or gallop;
pulses+2 bilat pedal and +2 radial
ABD: benign, nabs x 4, no organomegaly; mild suprapubic
tenderness – diffuse – no rebound
Genital/Rectal: external genitalia intact, no cervical motion
tenderness, no adnexal masses.
Musculoskeletal: symmetric muscle development - some age
related atrophy; muscle strengths 5/5 all groups.
Neuro: CN II – XII grossly intact, DTR’s intact
Skin/Lymph Nodes: No edema, clubbing, or cyanosis; no
palpable nodes
ASSESSMENT:
Lab Tests and Results:

6. CBC – WBC 15,000 with + left shift
SAO2 – 98%
Diagnostics:
Lab:
Radiology:
CXR – cardiomegaly with air trapping and increased AP
diameter
ECG
Normal sinus rhythm
Differential Diagnosis (DDx):
1.) Acute Bronchitis
2.) Pulmonary Embolis
3.) Lung Cancer
Diagnoses/Client Problems:
1.) COPD
2.) HTN, controlled
3.) Tobacco abuse – 40 pack year history
4.) Allergy to sulfa drugs – rash
5.) GERD – quiet on no current medication
PLAN: [This section is not required for the assignments in this
course, but will be required for future courses.]
© 2019 Walden University
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© 2019 Walden University
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Week 4 Lab Assignment: Differential Diagnosis for Skin

7. Conditions
1:
2:
3.
4.
5.
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Assignment 1: Lab Assignment: Differential Diagnosis for Skin
Conditions
TOPIC TO WRITE ON : • Benign nevi (interdermal)
Photo Credit: Getty Images/iStockphoto
Properly identifying the cause and type of a patient’s skin
condition involves a process of elimination known as
differential diagnosis. Using this process, a health professional
can take a given set of physical abnormalities, vital signs,
health assessment findings, and patient descriptions of
symptoms, and incrementally narrow them down until one
diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual
representations of various skin conditions, describe your
observations, and use the techniques of differential diagnosis to
determine the most likely condition.
To Prepare

8. · Review the Skin Conditions document provided in this week’s
Learning Resources, and select one condition to closely
examine for this Lab Assignment.
· Consider the abnormal physical characteristics you observe in
the graphic you selected. How would you describe the
characteristics using clinical terminologies?
· Explore different conditions that could be the cause of the skin
abnormalities in the graphics you selected.
· Consider which of the conditions is most likely to be the
correct diagnosis, and why.
· Search the Walden library for one evidence-based practice,
peer-reviewed article based on the skin condition you chose for
this Lab Assignment.
· Review the Comprehensive SOAP Exemplar found in this
week’s Learning Resources to guide you as you prepare your
SOAP note.
· Download the SOAP Template found in this week’s Learning
Resources, and use this template to complete this Lab
Assignment.
The Lab Assignment
· Choose one skin condition graphic (identify by number in your
Chief Complaint) to document your assignment in the SOAP
(Subjective, Objective, Assessment, and Plan) note format
rather than the traditional narrative style. Refer to Chapter 2 of
the Sullivan text and the Comprehensive SOAP Template in this
week's Learning Resources for guidance. Remember that not all
comprehensive SOAP data are included in every patient case.
· Use clinical terminologies to explain the physical
characteristics featured in the graphic. Formulate a differential
diagnosis of four to five possible conditions for the skin graphic
that you chose. Determine which is most likely to be the correct
diagnosis and explain your reasoning using at least three
different references, one reference from current evidence-based
literature from your search and two different references from
this week’s Learning Resources.

9. By Day 5 of Week 4
SUBMIT.