Week 5 Discussion NURS 6512
Case Study #2
Episodic/Focused SOAP Note Template
Lily is a 20-year-old student at the local community college.
When some of her friends and classmates told her about an outbreak of flu-like symptoms
sweeping her campus over the past two weeks,
Lily figured she shouldn't take her three-day sore throat lightly.
Your clinic has treated a few cases similar to Lily's.
All the patients reported decreased appetite, headaches, and pain with swallowing.
As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight
hoarseness in her voice but doesn't sound congested.
Patient Information:
L.X., 20y/o, female, Caucasian
S.
CC: Patient reports to clinic with c/o a “sore throat”.
HPI: L.X. is a 20 y/o Caucasian female college student presenting to clinic with a sore throat x 3
days with associated headache, painful swallowing and decreased appetite. She reports that
students at her college have been experiencing “flu-like symptoms x 2 weeks.
Location: throat
Onset: 3 days ago
Character: constant
Associated signs and symptoms: decreased appetite, headaches, pain with swallowing
, Timing: After attending classes on Monday.
Exacerbating/ relieving factors: Pain increases with swallowing, reports relief from cold
drinks, ibuprofen has helped reduce headaches temporarily, throat lozenges provide relief to
throat discomfort.
Severity: 6/10 pain scale
Current Medications: Ibuprofen 400mg every 4hrs PRN, Cepacol 1 Lozenge Every 2 Hours
Allergies: NKA
PMHx: Last tetanus was June 2016, flu shot October 2018, denies chronic or past major illness
and denies surgery.
Soc Hx: XL is from rural Illinois, attends Metro Community College full time, majoring in
elementary education, where she is an active member of the school volleyball team. She works
part time at a child development center. She is currently not in a committed relationship,
heterosexual and is sexually active using condoms for contraception. She denies using illicit or
prescription drugs, she smokes when she drinks and drinks only in social situations once or twice
a week in moderation. She currently lives alone and visits her parents every Sunday.
Fam Hx:
Mother: age 48, Multiple Sclerosis
Father: age 52, HTN and hyperlipidemia
Siblings: 1 younger brother with no significant health history
Maternal Grandmother: died at 83, CVA
Maternal Grandfather: died at age 78, renal cancer
Paternal Grandmother: age 82, living HTN, DM2
Paternal Grandfather: died at 58 due to MI
ROS: cover all body systems that may help you include or rule out a differential diagnosis You
should list each system as follows: General: Head: EENT: etc. You should list these in bullet
format and document the systems in order from head to toe.
HEENT: Eyes: PERRLA, no visual loss, blurred or double vision, sclera clear
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose with clear drainage and
sore throat.
Case Study #2
Episodic/Focused SOAP Note Template
Lily is a 20-year-old student at the local community college.
When some of her friends and classmates told her about an outbreak of flu-like symptoms
sweeping her campus over the past two weeks,
Lily figured she shouldn't take her three-day sore throat lightly.
Your clinic has treated a few cases similar to Lily's.
All the patients reported decreased appetite, headaches, and pain with swallowing.
As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight
hoarseness in her voice but doesn't sound congested.
Patient Information:
L.X., 20y/o, female, Caucasian
S.
CC: Patient reports to clinic with c/o a “sore throat”.
HPI: L.X. is a 20 y/o Caucasian female college student presenting to clinic with a sore throat x 3
days with associated headache, painful swallowing and decreased appetite. She reports that
students at her college have been experiencing “flu-like symptoms x 2 weeks.
Location: throat
Onset: 3 days ago
Character: constant
Associated signs and symptoms: decreased appetite, headaches, pain with swallowing
, Timing: After attending classes on Monday.
Exacerbating/ relieving factors: Pain increases with swallowing, reports relief from cold
drinks, ibuprofen has helped reduce headaches temporarily, throat lozenges provide relief to
throat discomfort.
Severity: 6/10 pain scale
Current Medications: Ibuprofen 400mg every 4hrs PRN, Cepacol 1 Lozenge Every 2 Hours
Allergies: NKA
PMHx: Last tetanus was June 2016, flu shot October 2018, denies chronic or past major illness
and denies surgery.
Soc Hx: XL is from rural Illinois, attends Metro Community College full time, majoring in
elementary education, where she is an active member of the school volleyball team. She works
part time at a child development center. She is currently not in a committed relationship,
heterosexual and is sexually active using condoms for contraception. She denies using illicit or
prescription drugs, she smokes when she drinks and drinks only in social situations once or twice
a week in moderation. She currently lives alone and visits her parents every Sunday.
Fam Hx:
Mother: age 48, Multiple Sclerosis
Father: age 52, HTN and hyperlipidemia
Siblings: 1 younger brother with no significant health history
Maternal Grandmother: died at 83, CVA
Maternal Grandfather: died at age 78, renal cancer
Paternal Grandmother: age 82, living HTN, DM2
Paternal Grandfather: died at 58 due to MI
ROS: cover all body systems that may help you include or rule out a differential diagnosis You
should list each system as follows: General: Head: EENT: etc. You should list these in bullet
format and document the systems in order from head to toe.
HEENT: Eyes: PERRLA, no visual loss, blurred or double vision, sclera clear
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose with clear drainage and
sore throat.
