The University of Oklahoma

NURS 6313

SOAP NOTE TEMPLATE
SOAP NOTE # IV Patient Initials: I.S
I. Subjective Data
A. Chief Complaint (CC): “Flank pain”
B. History of Present Illness (HPI): Pt.is a 32 Y/O male who presented to the clinic
with a cc of “Flank pain”. He reports a horrible pain in the left flank that started a couple
of hours ago that radiates to his left groin. He reports his felt a discomfort last night and
though he pulled a muscle on his back. He describes his pain as sharp and stabbing that is
consistent and worsening at time and unrelieved with positioning , Tylenol, and ice and
heat. He rates his pain 7/10 and it makes it hard for him to get a full breath. He reports
nausea and vomiting several times since the pain started. Reports been kind of sweaty
since his pain started. Pt indicates his urine is dark and it is hard for him to initiate a
stream. He denies dysuria, urgency, and hematuria
C. Last Menstrual Period: (LMP- if applicable): N/A
D. Allergies: NKA
E. Past Medical History:
HTN, occasional backache, chickenpox as a child.
F. Family History:
HTN, DM, Heart disease.
Father: shingles
G. Surgery History: None reported
H. Social History/Lifestyle Patterns: Pt. is a contractor who is married with two
children. does not smoke nor use illicit drugs. He reports enjoying a beer or two on the
weekend with his buddies. No hard liquor.
I. Sexual Activity: Yes.
J. Health Maintenance:
Up to date on his immunization, including flu (Covid vaccines N/A).
He workout five to six times a week.
Well-balanced diet.
HCTZ; Tylenol (OTC).