Nurse Practitioner Soap Note

Prepared by: [Your Name]

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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

• Recommend starting cetirizine 10mg daily for seasonal allergy symptoms.

• Consider acetaminophen 500mg as needed for headaches.

B. Tests/Referrals

• TSH lab work was ordered to rule out thyroid dysfunction.

• Consider referral to an ENT specialist if symptoms persist.

C. Follow-Up

• Follow-up in 2 weeks or sooner if symptoms worsen.

• Contact the clinic if new symptoms arise or if headaches persist despite OTC treatments.

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