SOAP Note Week 4 NU610/ NU 610: Completed and Reviewed Latest 2026 - Herzing University.

SOAP Note Week 4 Name:___Amanda Bright
Typhon Encounter #: _____________________
NU 610:_________ Comprehensive:____Focused:____
Herzing University

S: SUBJECTIVE DATA
CC: Yearly Sports Physical.

HPI: Patient is a 14-year-old female presenting for her annual sports physical.
She reports no acute complaints. She enjoys playing volleyball and wishes
to maintain her health by continuing sports participation. Denies chest
pain, shortness of breath, palpitations, dizziness, or recent injuries. She
attends therapy for anxiety, which is well-controlled. She uses ibuprofen
or Tylenol occasionally for minor aches and pains, with good relief. She
denies any medication side effects, systemic symptoms, or new health
concerns.

PMH: Past medical history includes a diagnosis of a milk allergy identified
during infancy, which contributed to episodes of failure to thrive.
Currently, the patient is thriving in her teenage years. She experienced
multiple hospitalizations during her early years. Additionally, the patient
struggles with anxiety and is currently seeing a therapist. She also has a
known allergy to erythromycin, which elicits an anaphylactic reaction.

ALLERGIES  Erythromycin reaction “stops breathing”
 Fluid milk reactions: “projectile vomit”

MEDICATIONS Ibuprofen 200mg- 2 capsules every 6 hrs. as needed for pain/fever
Acetaminophen 500 mg- 2 Tablets every 6 hrs. as needed for pain/fever
SH Social History:
 Education: High school freshman
 Tobacco: Denies use
 Alcohol: Denies use
 Illicit Drugs: Denies use
 Caffeine: Moderate intake
 Marital/Relationship: Single
 Stressors: School peer pressure; attends therapy for anxiety
 Cultural/Religious: No religious affiliation
 Socioeconomics: Lives at home, stable family support
 Leisure: Enjoys playing volleyball
 Living Situation: Resides with mother, stepfather, older brother,
and younger brother on 5 acres
 Exercise: Regular through volleyball and school sports
 Nutrition: Balanced diet; avoids fluid milk
 Safety Habits: Wears a seatbelt, denies risky behaviors
Sexual History:
 Denies sexual activity

, SOAP Note Week 4 Name:___Amanda Bright
Typhon Encounter #: _____________________
NU 610:_________ Comprehensive:____Focused:____
Herzing University

 Pt denies the history of STIs.
 PT is interested in learning about birth control options
FH  Paternal Side: Unknown
 Maternal Side: POTS, Asthma, Anxiety
 Siblings: one older brother who is high-functioning autistic and
one younger half-brother who has ADHD
 Children: n/a


HEALTH Required for all SOAP notes:
PROMOTION & Vaccinations (CDC Recommended):
MAINTENANC 1. HPV: Completed 2-dose series
E 2. Meningococcal ACWY: Completed and up to date
3. Influenza: Up to date with annual vaccine
4. COVID-19: Declined
5. Catch-up vaccines: None needed at this time

Preventive Screenings (USPSTF Recommendations)
1. Anxiety screening (age 8–18)
2. Depression screening (age 12–18)
3. Obesity screening and BMI monitoring

Lifestyle & Counseling:
 Diet: Encourage healthier options; reduce processed foods and
sugary beverages
 Exercise: Encourage structured activity as feasible
 Safety: Continue seatbelt use and protective measures at
work/home
 Tobacco: Discuss smoking cessation options
 Alcohol & substance use: Continue to avoid
 Stress management: Support continued therapy for anxiety
 Leisure: Encourage ongoing recreational activities for mental
health
ROS Constitutional Denies fatigue, fever, or weight
changes
(put N/A in sections Denies headaches or trauma
Head