CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) N. J. Date: 05/13/2025 Time: 2:00 PM
Ethnicity: African American Age: 16 Sex: Female
SUBJECTIVE (must complete this section)
CC : My throat is hurting so bad. It hurts when I swallow anything, and it has kept me up every night up and
down for the past three nights. My fever was 102.3 last night."
HPI: The patient is a new patient who is a 16-year-old African American female presenting in office with her
mother. She reports severe throat pain that has been ongoing for 3 days. The pain is described as intense,
affecting swallowing of all substances including water, food, and even saliva. The patient reports a fever of
102.3°F last night and has been taking Tylenol for pain relief, though it provides minimal relief. Associated
symptoms include headache, cough, nausea, significant mucus production and congestion. The patient observed
white patches on their tonsils upon self-examination. They deny having a runny nose. The severity of the throat
pain is described as "killing me," significantly impacting the patient's ability to eat and drink. The patient
reports no known sick contacts and is unsure of the source of their illness. The patient has attempted self-
treatment with Tylenol but finds it ineffective in managing the pain. The throat pain and difficulty swallowing
have affected the patient's daily functioning, particularly their ability to maintain proper hydration and
nutrition.
Medications :
- Tylenol 500mg tablets. Take 2 tablets every 4 hours by oral route as needed. Do not give more than 5
times in 24 hours.
Previous Medical History: No previous medical history
Developmental History:
Allergies: Pineapple/pineapple flavoring: facial swelling, moderate
Medication Intolerances: All medication with pineapple flavoring: facial swelling, moderate
Chronic Illnesses/Major traumas: No chronic illnesses or major traumas
Immunizations: All immunizations up to date besides COVID vaccination refused by parent and
patient.
Hospitalizations/Surgeries: No hospitalizations or surgeries
Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: appropriate dairy intake: 3 servings of milk, cheese or yogurt a day and
Calcium intake; diet includes daily vegetables and fruits; and 3 meals/day, does not skip meals, well
balanced diet, including protein and iron-rich foods, fast food <1 time per week, <8oz. sugar
containing beverages daily, 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: Injury Prevention: no smokers in home/smokers around child, guns in
home/homes where child spends time, or concern for violence in home; has emergency
numbers/poison control number near every telephone and fire safety/escape plan; and smoke
detectors on every floor, regularly tests alarms, CO detectors on every floor, regularly tests alarms,
always uses car seat or booster seat in the back seat of car, safe practices around pool & water,
understanding of sun protection, understands insect repellant, hot water temperature set at or below
120F, uses helmet for biking/scootering, and no swimming lessons.
Screening exams: Hearing Screening - based on risk assessment: Parental concerns with child's
hearing: No and speech: No. Vision Screening - based on risk assessment: 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 assessment: Was child or any household member born in, or has traveled to, a
country where tuberculosis is common (Includes countries in Africa, Asia, Latin America, Eastern
, Europe)? No, has child had close contact with a person who has tuberculosis disease or who has
had a positive tuberculosis test result? No, and Is child infected with HIV? No.
FAMILY HISTORY (must complete this section)
M: 40 years old. Alive and well. No acute or chronic illnesses reported.
MGM: 60 years old. Alive and well. History of breast cancer, diabetes, and hypertension
MGF: Deceased. History of metastatic lung cancer.
F: 39 years old. Alive and well. No acute or chronic illnesses reported.
PGM: Deceased before patient was born. No acute or chronic illnesses reported by parent.
PGF: Deceased before patient was born. No acute or chronic illnesses reported by parent.
Social History: Patient lives with both parents and little sister in a 4-bedroom home. Patient attends a local high
school and is currently enrolled in the 10 th grade heading to 11th in August 2025. Patient denies any drug or
alcohol use. Patient reports the occasional intake of caffeine, though rare. Patient denies any form of sexual
encounters. Patient reports she is doing well in school and gets along well with her peers.
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, headache, cough, sore throat, nausea, Cardiovascular: Denial of any chest pain.
and congestion.
Skin: Denial of any rashes or bruises. No report of trauma. Respiratory: Report of productive cough.
Denies wheezing.
Eyes: Denial of any eye discharge. Denies blurred vision or eye Gastrointestinal: Report of nausea. Denies
pain. vomiting or diarrhea.
Ears: Denial of ear discharge. Denial of any past or current Genitourinary/Gynecological: Denies
hearing disorders urinary frequency or urgency.
Nose/Mouth/Throat: Report severe sore throat. Reports of Musculoskeletal: Denies joint swelling.
nasal congestion. Denies runny nose. Denies body aches.
Breast: Denies any pain/tenderness Neurological: Reports headaches. Denies
weakness or loss of consciousness.
Heme/Lymph/Endo: Denies abnormal bleeding or easy Psychiatric: Denies any symptoms of
bruising. No history of blood disorders. depression or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 20
110 lbs. 5 oz. 5 ft. 3 in 19.6 118/74 101.4 88 SPO2%: 99%
General Appearance: Patient is alert and sitting down conversing with her mother in a chair in examination
room. Patient is attentive and can answer questions when asked. Patient noted to have a hoarse voice.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is hot to touch. Patient’s fever noted to
be 101.4 oral in office.
HEENT: Head is normocephalic and atraumatic. PERRLA. Right and left tympanic membrane pearly w/ good
landmarks. Dried mucous noted to nasal passages, which are narrow. Enlarged tonsil size at a grade 2 with
white exudate. 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. Productive cough noted with clear mucous. No wheezing noted
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.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted.
Neurological: Cranial nerves grossly intact.
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) N. J. Date: 05/13/2025 Time: 2:00 PM
Ethnicity: African American Age: 16 Sex: Female
SUBJECTIVE (must complete this section)
CC : My throat is hurting so bad. It hurts when I swallow anything, and it has kept me up every night up and
down for the past three nights. My fever was 102.3 last night."
HPI: The patient is a new patient who is a 16-year-old African American female presenting in office with her
mother. She reports severe throat pain that has been ongoing for 3 days. The pain is described as intense,
affecting swallowing of all substances including water, food, and even saliva. The patient reports a fever of
102.3°F last night and has been taking Tylenol for pain relief, though it provides minimal relief. Associated
symptoms include headache, cough, nausea, significant mucus production and congestion. The patient observed
white patches on their tonsils upon self-examination. They deny having a runny nose. The severity of the throat
pain is described as "killing me," significantly impacting the patient's ability to eat and drink. The patient
reports no known sick contacts and is unsure of the source of their illness. The patient has attempted self-
treatment with Tylenol but finds it ineffective in managing the pain. The throat pain and difficulty swallowing
have affected the patient's daily functioning, particularly their ability to maintain proper hydration and
nutrition.
Medications :
- Tylenol 500mg tablets. Take 2 tablets every 4 hours by oral route as needed. Do not give more than 5
times in 24 hours.
Previous Medical History: No previous medical history
Developmental History:
Allergies: Pineapple/pineapple flavoring: facial swelling, moderate
Medication Intolerances: All medication with pineapple flavoring: facial swelling, moderate
Chronic Illnesses/Major traumas: No chronic illnesses or major traumas
Immunizations: All immunizations up to date besides COVID vaccination refused by parent and
patient.
Hospitalizations/Surgeries: No hospitalizations or surgeries
Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: appropriate dairy intake: 3 servings of milk, cheese or yogurt a day and
Calcium intake; diet includes daily vegetables and fruits; and 3 meals/day, does not skip meals, well
balanced diet, including protein and iron-rich foods, fast food <1 time per week, <8oz. sugar
containing beverages daily, 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: Injury Prevention: no smokers in home/smokers around child, guns in
home/homes where child spends time, or concern for violence in home; has emergency
numbers/poison control number near every telephone and fire safety/escape plan; and smoke
detectors on every floor, regularly tests alarms, CO detectors on every floor, regularly tests alarms,
always uses car seat or booster seat in the back seat of car, safe practices around pool & water,
understanding of sun protection, understands insect repellant, hot water temperature set at or below
120F, uses helmet for biking/scootering, and no swimming lessons.
Screening exams: Hearing Screening - based on risk assessment: Parental concerns with child's
hearing: No and speech: No. Vision Screening - based on risk assessment: 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 assessment: Was child or any household member born in, or has traveled to, a
country where tuberculosis is common (Includes countries in Africa, Asia, Latin America, Eastern
, Europe)? No, has child had close contact with a person who has tuberculosis disease or who has
had a positive tuberculosis test result? No, and Is child infected with HIV? No.
FAMILY HISTORY (must complete this section)
M: 40 years old. Alive and well. No acute or chronic illnesses reported.
MGM: 60 years old. Alive and well. History of breast cancer, diabetes, and hypertension
MGF: Deceased. History of metastatic lung cancer.
F: 39 years old. Alive and well. No acute or chronic illnesses reported.
PGM: Deceased before patient was born. No acute or chronic illnesses reported by parent.
PGF: Deceased before patient was born. No acute or chronic illnesses reported by parent.
Social History: Patient lives with both parents and little sister in a 4-bedroom home. Patient attends a local high
school and is currently enrolled in the 10 th grade heading to 11th in August 2025. Patient denies any drug or
alcohol use. Patient reports the occasional intake of caffeine, though rare. Patient denies any form of sexual
encounters. Patient reports she is doing well in school and gets along well with her peers.
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, headache, cough, sore throat, nausea, Cardiovascular: Denial of any chest pain.
and congestion.
Skin: Denial of any rashes or bruises. No report of trauma. Respiratory: Report of productive cough.
Denies wheezing.
Eyes: Denial of any eye discharge. Denies blurred vision or eye Gastrointestinal: Report of nausea. Denies
pain. vomiting or diarrhea.
Ears: Denial of ear discharge. Denial of any past or current Genitourinary/Gynecological: Denies
hearing disorders urinary frequency or urgency.
Nose/Mouth/Throat: Report severe sore throat. Reports of Musculoskeletal: Denies joint swelling.
nasal congestion. Denies runny nose. Denies body aches.
Breast: Denies any pain/tenderness Neurological: Reports headaches. Denies
weakness or loss of consciousness.
Heme/Lymph/Endo: Denies abnormal bleeding or easy Psychiatric: Denies any symptoms of
bruising. No history of blood disorders. depression or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 20
110 lbs. 5 oz. 5 ft. 3 in 19.6 118/74 101.4 88 SPO2%: 99%
General Appearance: Patient is alert and sitting down conversing with her mother in a chair in examination
room. Patient is attentive and can answer questions when asked. Patient noted to have a hoarse voice.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is hot to touch. Patient’s fever noted to
be 101.4 oral in office.
HEENT: Head is normocephalic and atraumatic. PERRLA. Right and left tympanic membrane pearly w/ good
landmarks. Dried mucous noted to nasal passages, which are narrow. Enlarged tonsil size at a grade 2 with
white exudate. 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. Productive cough noted with clear mucous. No wheezing noted
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.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted.
Neurological: Cranial nerves grossly intact.
