CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 07/03/24 Time: 1039
F.B.
Ethnicity: Black Age: 15 Sex: M
SUBJECTIVE (must complete this section)
CC: Runny nose, congestion, sore throat, and cough for 5 days
HPI: The patient reports a runny nose, nasal congestion, sore throat, and a non-productive cough that started 5
days ago. The symptoms have progressively worsened, and he now experiences mild headaches and fatigue. He
denies any fever, chills, or shortness of breath. He has not taken any medication for his symptoms.
Medications:
Previous Medical History: None
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Alive- no
hx F:
unknown
Social History : The patient is a non-smoker, denies alcohol and drug use. Lives with parents and two siblings. No
recent travel history.
REVIEW OF SYSTEMS (must complete this
section)
General: Denies fatigue, night sweats and Cardiovascular: Denies syncope, edema,
weakness shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Reports productive cough,
denies difficulty breathing, shortness of
breath, labored breathing, tachypnea,
wheezing, retractions, and
stridor
Eyes: Denies and visual changes, eye Gastrointestinal: Denies abdominal pain,
drainage or eye pain spitting up/vomiting, diarrhea, and changes in
stool.
Ears: Denies ear pain and swelling Genitourinary/Gynecological: Denies
increased urine output, dysuria. Denies foul
urine and
hematuria
Nose/Mouth/Throat: Reports nasal Musculoskeletal: Denies weakness,
congestions, restriction of
runny nose and sore throt movement, joint swelling.
Breast: Deferred Neurological: Denies abnormal activity,
abnormal movements, and changes in
strength.
Heme/Lymph/Endo: Denies swollen Psychiatric: Denies symptoms of
glands, bruising, bleeding, and edema. depression,
anxiety, mood swings, hallucinations,
, delusions, or behavioral disturbances.
OBJECTIVE (Document PERTINENT systems only,
Minimum 3)
Weight: H eight: BMI: BP: Temp: 37 Pulse: 78 Resp: 16
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 07/03/24 Time: 1039
F.B.
Ethnicity: Black Age: 15 Sex: M
SUBJECTIVE (must complete this section)
CC: Runny nose, congestion, sore throat, and cough for 5 days
HPI: The patient reports a runny nose, nasal congestion, sore throat, and a non-productive cough that started 5
days ago. The symptoms have progressively worsened, and he now experiences mild headaches and fatigue. He
denies any fever, chills, or shortness of breath. He has not taken any medication for his symptoms.
Medications:
Previous Medical History: None
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Alive- no
hx F:
unknown
Social History : The patient is a non-smoker, denies alcohol and drug use. Lives with parents and two siblings. No
recent travel history.
REVIEW OF SYSTEMS (must complete this
section)
General: Denies fatigue, night sweats and Cardiovascular: Denies syncope, edema,
weakness shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Reports productive cough,
denies difficulty breathing, shortness of
breath, labored breathing, tachypnea,
wheezing, retractions, and
stridor
Eyes: Denies and visual changes, eye Gastrointestinal: Denies abdominal pain,
drainage or eye pain spitting up/vomiting, diarrhea, and changes in
stool.
Ears: Denies ear pain and swelling Genitourinary/Gynecological: Denies
increased urine output, dysuria. Denies foul
urine and
hematuria
Nose/Mouth/Throat: Reports nasal Musculoskeletal: Denies weakness,
congestions, restriction of
runny nose and sore throt movement, joint swelling.
Breast: Deferred Neurological: Denies abnormal activity,
abnormal movements, and changes in
strength.
Heme/Lymph/Endo: Denies swollen Psychiatric: Denies symptoms of
glands, bruising, bleeding, and edema. depression,
anxiety, mood swings, hallucinations,
, delusions, or behavioral disturbances.
OBJECTIVE (Document PERTINENT systems only,
Minimum 3)
Weight: H eight: BMI: BP: Temp: 37 Pulse: 78 Resp: 16
