Internal Medicine Soap Note

SOAP Note

Prepared by Sherri R. Williams, Fusion Edge Technologies

Introduction

The SOAP note herein is a comprehensive documentation of the diagnosis and sessions summary for patient James Young, a 39-year-old male, standing at 5'10" and weighing 170 lbs. This note is constructed against the standard method of documentation in Internal Medicine which encapsulates four main aspects: Subjective, Objective, Assessment, and Plan (SOAP).

Subjective	Objective	Assessment	Plan
Reports feeling fatigued Mild continuous headaches Shortness of breath during mild activities	Vital signs: BP 140/90 mmHg, Pulse 85 bpm, Temp 98.6 F, Respiratory rate 18/min Physical exam reveals body mass index within healthy range. Chest sounds clear, cardiovascular exam reveals a regular rhythm	The patient's symptoms of fatigue, headaches, and shortness of breath suggest probable hypertension. Further diagnostic tests required to confirm such suspicions.	Request for diagnostic tests including but not limited to ECG and blood tests Lifestyle modifications are advised i.e., reducing salt intake and increasing physical activity Follow-up appointment to be scheduled for result interpretation and medication initiation if necessary