Ya33`assCONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) E.C. Date: 04/14/2025 Time: 1030 AM
Ethnicity: Caucasian Age: 7 Sex: Male
SUBJECTIVE (must complete this section)
CC : Per mother: "He’s been complaining of his left ear hurting since last night at church. He said that it’s hard
to hear from that ear too. His whole left ear was red like blood. He also has been coughing and complaining of
a sore throat"
HPI: The patient is a 7-year-old Caucasian male presenting in office with his mother with
complaints of left ear pain that began last night while at church. The patient's mother reports
that the entire ear appeared blood red. The patient complains of difficulty hearing from the
affected ear, describing it as sounding "hard." The mother was able to visualize redness inside
the ear by pulling it back slightly. The patient has also been coughing and complains of throat
pain. The patient reports feeling warm, suggesting a possible fever, though his temperature was
normal when checking. Patient’s symptoms have been present for 1 day. Patient’s mother denies
sick contacts at home. Mother reports lying down on affected side makes ear pain worse. Mother
has not tried over-
the-counter medications.
Medications:
No current medications.
Previous Medical History: Beta Thalassemia trait, Congenital blocked tear duct of left
eye, Seasonal allergic rhinitis
Developmental History:
Allergies: No known diagnosed allergies
Medication Intolerances: No known Medication Intolerances
Chronic Illnesses/Major traumas: Beta Thalassemia trait, Congenital blocked tear duct of
left eye, Seasonal allergic rhinitis
Immunizations: Immunizations up to date. Refused COVID/FLU
Hospitalizations/Surgeries: Circumcision at birth, Tonsillectomy at age
5. Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: Promote healthy eating habits by providing healthy foods,
such as vegetables, fruits, lean protein and whole grains, and being a role model in
what you eat. Encourage 2-3 servings each day of low-fat dairy foods. Limit candy,
sweetened beverages, and sugary foods. Adequate daily water intake and eats meals
as a family.
Exercise/Regimen: Exercises every day, plays outside, limits TV/electronic use.
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: No passive exposure and no
smokers/drinkers/drug use in home
Safety Measures: Educated that child should always ride in the back seat (until at
least 13 years of age, how to safely cross the street and ride the school bus. Discuss
stranger safety, firearm safety, water safety, seat belt use. Provide a proper fitting
helmet and safety gear for riding scooters, biking, skating, in-line skating, skiing,
snowboarding, and horseback riding. Never let your child swim alone. Install
working smoke and carbon monoxide detectors on every floor, test monthly and
change batteries every year. Make a family escape plan in case of fire in your home.
If it is necessary to keep a gun in your home, store it unloaded and locked with the
ammunition locked separately. If there are guns in homes where your child plays,
make sure they are stored safely.
Screening exams: Parental concerns with child's hearing: No and speech: No. Concerns
with child's vision: No. Anemia Screening - based on risk assessment: Does child eat a
vegetarian diet (does not eat red meat, chicken, fish, or seafood)? No, child's diet
includes iron-rich foods, such as meat, iron- fortified cereals, or beans? Yes, and family
struggle to put food on the table? No. Dyslipidemia Screening - based on risk
assessment: Dyslipidemia screen indicated: No. Tuberculosis Screening - based on risk
, FAMILY HISTORY (must complete this section)
M: 31 years of age. Alive and well. History of Beta Thalassemia.
MGM: 57 years of age. Alive and well History of Beta Thalassemia
trait. MGF: Unknown acute or chronic illnesses, unknown age.
F: 32 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGM: 58 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGF: 58 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever since last night ranging from 100.0 to Cardiovascular: Denies complaints of chest
100.4. Denies nasal congestion. Reports throat pain and cough. pain
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Denies SOB or wheezing.
Eyes: Denies eye discharge, blurred vision, or eye pain Gastrointestinal: Denies nausea, vomiting,
or diarrhea
Ears: Denies ear discharge. Denies previous ear disorder or Genitourinary/Gynecological: Denies
drainage. urinary frequency urgency, or pain.
Nose/Mouth/Throat: Denies nasal drainage or congestion. Musculoskeletal: Denies joint swelling,
aches, or pain.
Breast: Denies pain or tenderness Neurological: Denies any loss of
consciousness. Denial of any weakness
Heme/Lymph/Endo: Denies abnormal bleeding or easy Psychiatric: Denies symptoms depression
bruising. History of beta thalassemia trait and mother or anxiety
diagnosed with beta thalassemia.
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 18
68 lbs. 0 oz 4 ft. 4.5 in 17.3 92/60 98.7 106 SPO2%: 99%
General Appearance: Patient is alert and sitting in a chair in the room Patient is attentive and can answer
questions when asked with no difficulties. Patient is noted to be afebrile. Patient also noted to have a
nonproductive cough.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch. No rashes or
abnormalities noted.
HEENT: Head is normocephalic and atraumatic. PERRLA. tympanic membrane(s) erythematous
bilaterally, right tympanic membrane with serous effusion, left tympanic membrane bulging (canal red
bilaterally. left tm with small bullae.) Nasal passages patent. Tonsils are appropriate size, no exudate noted.
Erythematous throat mucosa.
Cardiovascular: S1 and S2 sounds heard. No abnormal murmurs. No chest deformities. No edema. Capillary
refill <2 seconds on all four extremities
Respiratory: O2 saturation 99% on room air. Non-productive cough noted. No wheezing upon auscultation.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge. No skin discoloration.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted without tenderness.
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, and Strep throat testing performed in office to rule out any of these
infections
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) E.C. Date: 04/14/2025 Time: 1030 AM
Ethnicity: Caucasian Age: 7 Sex: Male
SUBJECTIVE (must complete this section)
CC : Per mother: "He’s been complaining of his left ear hurting since last night at church. He said that it’s hard
to hear from that ear too. His whole left ear was red like blood. He also has been coughing and complaining of
a sore throat"
HPI: The patient is a 7-year-old Caucasian male presenting in office with his mother with
complaints of left ear pain that began last night while at church. The patient's mother reports
that the entire ear appeared blood red. The patient complains of difficulty hearing from the
affected ear, describing it as sounding "hard." The mother was able to visualize redness inside
the ear by pulling it back slightly. The patient has also been coughing and complains of throat
pain. The patient reports feeling warm, suggesting a possible fever, though his temperature was
normal when checking. Patient’s symptoms have been present for 1 day. Patient’s mother denies
sick contacts at home. Mother reports lying down on affected side makes ear pain worse. Mother
has not tried over-
the-counter medications.
Medications:
No current medications.
Previous Medical History: Beta Thalassemia trait, Congenital blocked tear duct of left
eye, Seasonal allergic rhinitis
Developmental History:
Allergies: No known diagnosed allergies
Medication Intolerances: No known Medication Intolerances
Chronic Illnesses/Major traumas: Beta Thalassemia trait, Congenital blocked tear duct of
left eye, Seasonal allergic rhinitis
Immunizations: Immunizations up to date. Refused COVID/FLU
Hospitalizations/Surgeries: Circumcision at birth, Tonsillectomy at age
5. Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: Promote healthy eating habits by providing healthy foods,
such as vegetables, fruits, lean protein and whole grains, and being a role model in
what you eat. Encourage 2-3 servings each day of low-fat dairy foods. Limit candy,
sweetened beverages, and sugary foods. Adequate daily water intake and eats meals
as a family.
Exercise/Regimen: Exercises every day, plays outside, limits TV/electronic use.
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: No passive exposure and no
smokers/drinkers/drug use in home
Safety Measures: Educated that child should always ride in the back seat (until at
least 13 years of age, how to safely cross the street and ride the school bus. Discuss
stranger safety, firearm safety, water safety, seat belt use. Provide a proper fitting
helmet and safety gear for riding scooters, biking, skating, in-line skating, skiing,
snowboarding, and horseback riding. Never let your child swim alone. Install
working smoke and carbon monoxide detectors on every floor, test monthly and
change batteries every year. Make a family escape plan in case of fire in your home.
If it is necessary to keep a gun in your home, store it unloaded and locked with the
ammunition locked separately. If there are guns in homes where your child plays,
make sure they are stored safely.
Screening exams: Parental concerns with child's hearing: No and speech: No. Concerns
with child's vision: No. Anemia Screening - based on risk assessment: Does child eat a
vegetarian diet (does not eat red meat, chicken, fish, or seafood)? No, child's diet
includes iron-rich foods, such as meat, iron- fortified cereals, or beans? Yes, and family
struggle to put food on the table? No. Dyslipidemia Screening - based on risk
assessment: Dyslipidemia screen indicated: No. Tuberculosis Screening - based on risk
, FAMILY HISTORY (must complete this section)
M: 31 years of age. Alive and well. History of Beta Thalassemia.
MGM: 57 years of age. Alive and well History of Beta Thalassemia
trait. MGF: Unknown acute or chronic illnesses, unknown age.
F: 32 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGM: 58 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGF: 58 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever since last night ranging from 100.0 to Cardiovascular: Denies complaints of chest
100.4. Denies nasal congestion. Reports throat pain and cough. pain
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Denies SOB or wheezing.
Eyes: Denies eye discharge, blurred vision, or eye pain Gastrointestinal: Denies nausea, vomiting,
or diarrhea
Ears: Denies ear discharge. Denies previous ear disorder or Genitourinary/Gynecological: Denies
drainage. urinary frequency urgency, or pain.
Nose/Mouth/Throat: Denies nasal drainage or congestion. Musculoskeletal: Denies joint swelling,
aches, or pain.
Breast: Denies pain or tenderness Neurological: Denies any loss of
consciousness. Denial of any weakness
Heme/Lymph/Endo: Denies abnormal bleeding or easy Psychiatric: Denies symptoms depression
bruising. History of beta thalassemia trait and mother or anxiety
diagnosed with beta thalassemia.
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 18
68 lbs. 0 oz 4 ft. 4.5 in 17.3 92/60 98.7 106 SPO2%: 99%
General Appearance: Patient is alert and sitting in a chair in the room Patient is attentive and can answer
questions when asked with no difficulties. Patient is noted to be afebrile. Patient also noted to have a
nonproductive cough.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch. No rashes or
abnormalities noted.
HEENT: Head is normocephalic and atraumatic. PERRLA. tympanic membrane(s) erythematous
bilaterally, right tympanic membrane with serous effusion, left tympanic membrane bulging (canal red
bilaterally. left tm with small bullae.) Nasal passages patent. Tonsils are appropriate size, no exudate noted.
Erythematous throat mucosa.
Cardiovascular: S1 and S2 sounds heard. No abnormal murmurs. No chest deformities. No edema. Capillary
refill <2 seconds on all four extremities
Respiratory: O2 saturation 99% on room air. Non-productive cough noted. No wheezing upon auscultation.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge. No skin discoloration.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted without tenderness.
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, and Strep throat testing performed in office to rule out any of these
infections
