S.O.A.P Note Katherine Harris Completed by: Marissa Huettman
Subjective:
CC: Cough, SOB
HPI: Katherine is a 16 yo female who presents with cough x 3 weeks and SOB that has
developed and worsened over the last 3 days. She notes SOB with minimal exertion such as
walking short distances. Pt states cold like symptoms 3 weeks ago as well but have since
resolved. Pt notes feeling “wheezes” and chest tightness. Pt denies fevers, chills or sputum with
cough. Pt notes rest makes SOB better. Pt states pertinent history bouts of similar SOB over the
past 3 years with improvement quickly after. She is exposed to second hand smoke and
cockroaches as well.
PMH: Eczema
Surgical: Denies
SH:
Housing: With parents in apartment, exposed to cockroaches.
Recent Travel: Denies
Pets: Denies
Smoking: Denies +second hand smoke
EtOH: Denies
Recreational substance use (past and present): Denies
Sexual History: Denies being sexually active.
FH: Father- eczema
Medications: Denies
Allergies: Denies
Immunizations: UTD
ROS:
General: Denies: Usual weight, recent weight change, weakness,
fatigue, fever, night sweats, anorexia, malaise
Head: Denies: Headache, head injury
Eyes: Denies: Vision, glasses/contact lens, date of last eye
examination, pain, redness, excessive tearing, double vision
(diplopia), floaters (spots in front of eyes), loss of any visual fields,
history of glaucoma or cataracts
Ears: Denies: Hearing loss, change in hearing, ringing in ears
(tinnitus), ear infections
Nose and Sinuses: Denies: Frequent colds, nasal stuffiness, hay
fever, nosebleeds (epistaxis), sinus trouble, obstruction,
discharge, pain, change in ability to smell, sneezing, post-nasal
drip, history of nasal polyps
This study source was downloaded by 100000842308420 from CourseHero.com on 02-28-2022 03:58:08 GMT -06:00
https://www.coursehero.com/file/80850861/Katherine-Harris-SOAPdocx/
Subjective:
CC: Cough, SOB
HPI: Katherine is a 16 yo female who presents with cough x 3 weeks and SOB that has
developed and worsened over the last 3 days. She notes SOB with minimal exertion such as
walking short distances. Pt states cold like symptoms 3 weeks ago as well but have since
resolved. Pt notes feeling “wheezes” and chest tightness. Pt denies fevers, chills or sputum with
cough. Pt notes rest makes SOB better. Pt states pertinent history bouts of similar SOB over the
past 3 years with improvement quickly after. She is exposed to second hand smoke and
cockroaches as well.
PMH: Eczema
Surgical: Denies
SH:
Housing: With parents in apartment, exposed to cockroaches.
Recent Travel: Denies
Pets: Denies
Smoking: Denies +second hand smoke
EtOH: Denies
Recreational substance use (past and present): Denies
Sexual History: Denies being sexually active.
FH: Father- eczema
Medications: Denies
Allergies: Denies
Immunizations: UTD
ROS:
General: Denies: Usual weight, recent weight change, weakness,
fatigue, fever, night sweats, anorexia, malaise
Head: Denies: Headache, head injury
Eyes: Denies: Vision, glasses/contact lens, date of last eye
examination, pain, redness, excessive tearing, double vision
(diplopia), floaters (spots in front of eyes), loss of any visual fields,
history of glaucoma or cataracts
Ears: Denies: Hearing loss, change in hearing, ringing in ears
(tinnitus), ear infections
Nose and Sinuses: Denies: Frequent colds, nasal stuffiness, hay
fever, nosebleeds (epistaxis), sinus trouble, obstruction,
discharge, pain, change in ability to smell, sneezing, post-nasal
drip, history of nasal polyps
This study source was downloaded by 100000842308420 from CourseHero.com on 02-28-2022 03:58:08 GMT -06:00
https://www.coursehero.com/file/80850861/Katherine-Harris-SOAPdocx/
