Meagan Mullany, BSN, RN
NUR 6121-800
SOAP Note: Well Visit
Patient: Xavier Daniels
SUBJECTIVE
CC: “I’m just here because I need a checkup from a new doctor.”
HPI: Xavier Daniels is a 54-year-old African American male who presents to the clinic to
establish care as a new patient. Mr. Daniels reports his last visit to the doctor was approximately
3.5 years ago. He stopped seeing his previous doctor due to losing his job and health insurance,
which rendered him unable to afford healthcare. As per Mr. Daniels, he now has a new job and
health insurance which provide him the opportunity to be seen today. He was told at his last visit
3.5 years ago that he had high blood pressure but has not had any treatment due to his lack of
health insurance and income.
PMH: Patient states he was diagnosed with high blood pressure upon his last visit to a physician
3 ½ years ago. Denies mental health conditions. Denies recent travel. Denies having age-
appropriate preventative care such as prostate exam and colonoscopy.
Past Surgical History: Denies surgical history. Denies previous hospitalizations.
Medications: Denies medications. Denies vitamins or supplements.
Allergies: Denies allergies to environment, pets, food, medications, or latex.
Immunizations: As per patient, has not received vaccinations since childhood.
Family History:
Mother (77) living with type 2 diabetes.
Father (72) deceased with history of hypertension and prostate cancer. Cause of death was
prostate cancer.
Sister (48) living with no known or reported medical issues.
Social History: Denies tobacco use, denies illicit drug use. Patient reports social alcohol use once
a week, with 5 drinks consumed in one sitting.
Physical activity – Reports being mobile during work. Reports enjoying bicycling for 20 minutes
once a week.
Sleep – Reports 7 hours a night. Reports occasionally waking up at night.
Nutrition – Eats three meals per day, one of which is fast food. Snacks on pretzels and chips.
Drinks green tea occasionally. Drinks 6-8 glasses of water per day
Social support – Reports being single. Has recently been in a relationship four months ago. Lives
alone in his apartment and does not have any children. Has a strong support system from his
friends and family.
