SOAP NOTE 4: PHARYNGITITS
Soap Note 4:
Pharyngitis Spring
Arbor University Brett
Locke
, Name: A.E. Date : 06/13/2020 Time : 1100
DOB: 03/01/2001 Sex: Female
Subjective
CC: Wellness exam
HPI:
Patient is a pleasant 19-year-old female who presents to the office today with complaints of a
sore throat. She states the symptoms have been present for roughly four days. The pain is worse
when she swallows or tries to speak. She describes the pain as sharp/stabbing in her throat.
Warm liquids are soothing. She has been taking Tylenol 650 mg every 8 hours but does not feel
this improves her symptoms with the exception of fever. She will experience fever without
Tylenol, with the highest at 101.1. She is afebrile in office today, but reports she last took
Tylenol 2 hours before her appointment. She rates the pain at 5/10 when at its worst. She denies
shortness of breath. She complains of fatigue. She is unsure of any sick contacts. She does not
believe she has been in contact with anyone who may have contracted COVID-19.
Medications: Tylenol 650 mg po q 8 hours prn
Allergies: NKDA
PMI
Illnesses/Injuries
Childhood- Varicella age
7 Adult- Healthy
Hospitalizations/Surgeries: None
Vaccinations
Influenza- 11/2019 Pneumovax- no hx Tetanus- 1/2012 HPV- 2012 Hep B- 2003
Health Maintenance:
Last mammogram- no history of mammogram
Last pap smear- no history of pap smear
Last colonoscopy- no history of colonoscopy
Last prostate exam- n/a
FH:
Stroke – no history
Diabetes – father
Lung disease – no history
HTN – father
Heart disease – paternal grandfather
Cancer – no history
SH:
Tobacco: Denies nicotine use ETOH: Denies alcohol use Illicit drugs: Denies history
of illicit drug use
ROS
Soap Note 4:
Pharyngitis Spring
Arbor University Brett
Locke
, Name: A.E. Date : 06/13/2020 Time : 1100
DOB: 03/01/2001 Sex: Female
Subjective
CC: Wellness exam
HPI:
Patient is a pleasant 19-year-old female who presents to the office today with complaints of a
sore throat. She states the symptoms have been present for roughly four days. The pain is worse
when she swallows or tries to speak. She describes the pain as sharp/stabbing in her throat.
Warm liquids are soothing. She has been taking Tylenol 650 mg every 8 hours but does not feel
this improves her symptoms with the exception of fever. She will experience fever without
Tylenol, with the highest at 101.1. She is afebrile in office today, but reports she last took
Tylenol 2 hours before her appointment. She rates the pain at 5/10 when at its worst. She denies
shortness of breath. She complains of fatigue. She is unsure of any sick contacts. She does not
believe she has been in contact with anyone who may have contracted COVID-19.
Medications: Tylenol 650 mg po q 8 hours prn
Allergies: NKDA
PMI
Illnesses/Injuries
Childhood- Varicella age
7 Adult- Healthy
Hospitalizations/Surgeries: None
Vaccinations
Influenza- 11/2019 Pneumovax- no hx Tetanus- 1/2012 HPV- 2012 Hep B- 2003
Health Maintenance:
Last mammogram- no history of mammogram
Last pap smear- no history of pap smear
Last colonoscopy- no history of colonoscopy
Last prostate exam- n/a
FH:
Stroke – no history
Diabetes – father
Lung disease – no history
HTN – father
Heart disease – paternal grandfather
Cancer – no history
SH:
Tobacco: Denies nicotine use ETOH: Denies alcohol use Illicit drugs: Denies history
of illicit drug use
ROS
