Nurse Practitioner Soap Note
Prepared by: [Your Name]
I. Subjective (S)
A. Chief Complaint
The patient reports feeling fatigued for the past two weeks, along with intermittent headaches and dizziness. Denies fever, nausea, or vomiting.
B. History of Present Illness (HPI)
The patient is a 34-year-old female with a history of seasonal allergies. She mentions the symptoms have been progressively worsening with no significant relief from over-the-counter antihistamines. The fatigue has affected her ability to perform daily activities, and the headaches are described as dull and throbbing, usually located at the temples.
C. Past Medical History (PMH)
No significant medical history. No known drug allergies. Immunizations are up to date.
D. Family History
Mother has hypertension; father has a history of type 2 diabetes.
E. Social History
Non-smoker. Occasional alcohol use. Works as a school teacher with moderate stress levels.
II. Objective (O)
A. Vital Signs:
Vital Sign | Measurement |
|---|
Blood Pressure | 118/76 mmHg |
Heart Rate | 72 bpm |
Respiratory Rate | 16 breaths/min |
Temperature | 98.6°F |
Oxygen Saturation | 98% on room air |
B. Physical Examination:
System | Findings |
|---|
General | Alert and oriented, no acute distress. |
HEENT | Mild nasal congestion, no sinus tenderness, pupils equal and reactive to light. |
Cardiovascular | Regular rhythm, no murmurs or gallops. |
Respiratory | Clear breath sounds bilaterally, no wheezing. |
Neurological | Alert and oriented x3, cranial nerves intact, no focal deficits noted. |
Musculoskeletal | Full range of motion in all limbs, no joint swelling or tenderness. |
C. Labs/Tests
Test | Result | Notes |
|---|
CBC | Normal | No signs of anemia or infection |
TSH | Pending | To rule out hypothyroidism |
Urinalysis | Normal | No abnormalities noted |
III. Assessment (A)
Condition | Explanation/Diagnosis | Notes |
|---|
Fatigue and Headaches | Likely secondary to stress and possible seasonal allergies. Differential includes tension-type headaches and sinusitis. | No fever or significant sinus tenderness to support sinusitis. |
Seasonal Allergies | This likely contributes to nasal congestion and mild fatigue. | Symptoms consistent with allergy exacerbation. |
Rule out Hypothyroidism | TSH is pending evaluation for thyroid dysfunction given the complaint of fatigue. | Hypothyroidism is considered due to ongoing fatigue without clear cause. |
IV. Plan (P)
A. Medications
B. Tests/Referrals
C. Follow-Up
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