NURS 5220 SOAP NOTE ASSIGNMENT 1 2026
UPDATED WITH COMPLETE SOLUTIONS 100%
VERIFIED SOLUTIONS UPDATED LATEST
SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
Name: A.M.
Age: 3 years Not indicated pertinent family
Gender: Female history
Reliability: Unreliable because of developmental stage.
Reliability is from the mother
Personal/Social Hx:
Chief Complaint/RFE: A.M. is the firstborn in her family. Fever and sore throat She was a term
baby. She eats
toddler food, drinks from a cup,
speaks well with friends and
family, and is normally playful.
, However, she changed her day
care and now she is clingy. She
cries more recently and it has
been hard trying to make A.M. go
to day care in the morning.
Hx Present Illness: (7 Variables but do not list as such)
A.M. is a 3-years-old female who comes to the clinic with complaints of fever and sore throat.
Her mother says that three days ago, A.M. came home from day care with a runny nose. She also
indicates that in the past three days, A.M. had increased nasal drainage, coughing, sore throat,
change in voice, and last night she had a low grade fever (tactile). She woke up during the night
while crying and hot with a temperature of 103.1 taken under her arm. The mother reports that
she gave A.M. Motrin 7ml and she went back to sleep although she was restless. The mother
reports that A.M. woke up later than normal with less energy, has taken about 2oz of milk and
no food intake today. She also reports that A.M. is irritable and clingy. She reports that initially
the nasal drainage was clear but today it is yellow and thick. She states that A.M. needs help
while blowing her nose. The nose is red and irritated. She denies any diarrhoea or vomiting. She
also denies any rash.
CURRENT HEALTH
Medications: Tylenol and Motrin 7mls
Allergies: NKFDA
Last PE & Screenings: 2months ago for her 3-year-old well child
Immunization Status: According to the mother, A.M. is up-to-date with her immunization LMP &
Birth Control (if applicable) : N/A
PMH
Illnesses & Trauma : Respiratory concerns and one incidence of fall Hospitalizations/Surgeries: N/A
OB Hx/Sexual Hx : N/A Emotional/Psy Hx : N/A REVIEW OF SYSTEMS
General: The mother reports fever, malaise, and reduced appetite. She denies vomiting, diarrhea. No rash Nutrition
The mother reports that A.M. takes a toddler diet and drinks from a cup. Today, she has taken 2oz of milk and no food
intake
Skin/Hair/Nails: Mom denies dry skin, rash, hair loss, or sores
HEENT: Mom reports that the child has a sore throat and yellow and thick drainage today. Three days ago, the nasal
drainage was clear. Denies blurred vision, hearing loss, or pain in the ears. Denies difficulty swallowing. Breasts: No
lumps
Respiratory: Mother reports coughing with no production of phlegm or pus. Denies dyspnea, wheezing, or shortness
of breath
CV/peripheral vascular: Denies chest pain, cyanosis, swelling, or palpitations. Denies swelling, cramping or pain in the
legs
GI: Denies nausea, vomiting, constipation, abdominal pain, or diarrhea
GU: Denies discharge, dysuria, polyuria
MSK: Denies pain in muscles or joints. Denies decreased range of motion
Psych : Denies confusion, anxiety, depression
Neuro: Denies headache, dizziness, numbness
Lymph/Heme/Endocrine: Denies polydipsia, polyuria, sweating. Denies enlarged nodes. Denies anemia, bleeding, or
bruising
O/ Physical Exam : T: 38.9oC P: 128 R: 24 BP: 100/72 HT: 32inches WT: 15kg
BMI: 22.7
General: Well-nourished for her age, cognitive function appropriate for her age, appears to be in distress, clean
Skin: Warm, dry, and intact. No rash, lesion, cyanosis, or pallor noted. Capillary refill of <3seconds
Head: Hair evenly distributed, no lesions. Normocephalic
EENT: PERRLA, EOMI, No exudate or haemorrhage note. Clear external auditory canals and tympanic membranes.
Septum midline, no polyps, normal pink mucosa, nares patent bilaterally, yellow and thick nasal discharge. Oral
mucosa pink and moist, inflamed tonsils, uvula, and pharynx. No ulceration, masses, lesions, or exudates
Neck: Symmetrical, supple, full range of motion, non-tender with no masses
Breasts/Chest: No lumps
UPDATED WITH COMPLETE SOLUTIONS 100%
VERIFIED SOLUTIONS UPDATED LATEST
SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
Name: A.M.
Age: 3 years Not indicated pertinent family
Gender: Female history
Reliability: Unreliable because of developmental stage.
Reliability is from the mother
Personal/Social Hx:
Chief Complaint/RFE: A.M. is the firstborn in her family. Fever and sore throat She was a term
baby. She eats
toddler food, drinks from a cup,
speaks well with friends and
family, and is normally playful.
, However, she changed her day
care and now she is clingy. She
cries more recently and it has
been hard trying to make A.M. go
to day care in the morning.
Hx Present Illness: (7 Variables but do not list as such)
A.M. is a 3-years-old female who comes to the clinic with complaints of fever and sore throat.
Her mother says that three days ago, A.M. came home from day care with a runny nose. She also
indicates that in the past three days, A.M. had increased nasal drainage, coughing, sore throat,
change in voice, and last night she had a low grade fever (tactile). She woke up during the night
while crying and hot with a temperature of 103.1 taken under her arm. The mother reports that
she gave A.M. Motrin 7ml and she went back to sleep although she was restless. The mother
reports that A.M. woke up later than normal with less energy, has taken about 2oz of milk and
no food intake today. She also reports that A.M. is irritable and clingy. She reports that initially
the nasal drainage was clear but today it is yellow and thick. She states that A.M. needs help
while blowing her nose. The nose is red and irritated. She denies any diarrhoea or vomiting. She
also denies any rash.
CURRENT HEALTH
Medications: Tylenol and Motrin 7mls
Allergies: NKFDA
Last PE & Screenings: 2months ago for her 3-year-old well child
Immunization Status: According to the mother, A.M. is up-to-date with her immunization LMP &
Birth Control (if applicable) : N/A
PMH
Illnesses & Trauma : Respiratory concerns and one incidence of fall Hospitalizations/Surgeries: N/A
OB Hx/Sexual Hx : N/A Emotional/Psy Hx : N/A REVIEW OF SYSTEMS
General: The mother reports fever, malaise, and reduced appetite. She denies vomiting, diarrhea. No rash Nutrition
The mother reports that A.M. takes a toddler diet and drinks from a cup. Today, she has taken 2oz of milk and no food
intake
Skin/Hair/Nails: Mom denies dry skin, rash, hair loss, or sores
HEENT: Mom reports that the child has a sore throat and yellow and thick drainage today. Three days ago, the nasal
drainage was clear. Denies blurred vision, hearing loss, or pain in the ears. Denies difficulty swallowing. Breasts: No
lumps
Respiratory: Mother reports coughing with no production of phlegm or pus. Denies dyspnea, wheezing, or shortness
of breath
CV/peripheral vascular: Denies chest pain, cyanosis, swelling, or palpitations. Denies swelling, cramping or pain in the
legs
GI: Denies nausea, vomiting, constipation, abdominal pain, or diarrhea
GU: Denies discharge, dysuria, polyuria
MSK: Denies pain in muscles or joints. Denies decreased range of motion
Psych : Denies confusion, anxiety, depression
Neuro: Denies headache, dizziness, numbness
Lymph/Heme/Endocrine: Denies polydipsia, polyuria, sweating. Denies enlarged nodes. Denies anemia, bleeding, or
bruising
O/ Physical Exam : T: 38.9oC P: 128 R: 24 BP: 100/72 HT: 32inches WT: 15kg
BMI: 22.7
General: Well-nourished for her age, cognitive function appropriate for her age, appears to be in distress, clean
Skin: Warm, dry, and intact. No rash, lesion, cyanosis, or pallor noted. Capillary refill of <3seconds
Head: Hair evenly distributed, no lesions. Normocephalic
EENT: PERRLA, EOMI, No exudate or haemorrhage note. Clear external auditory canals and tympanic membranes.
Septum midline, no polyps, normal pink mucosa, nares patent bilaterally, yellow and thick nasal discharge. Oral
mucosa pink and moist, inflamed tonsils, uvula, and pharynx. No ulceration, masses, lesions, or exudates
Neck: Symmetrical, supple, full range of motion, non-tender with no masses
Breasts/Chest: No lumps
