CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) M.R. Date: 03/18/2025 Time: 10:15
Ethnicity: Black/African American Age: 7 Sex: Female
SUBJECTIVE (must complete this section)
CC : Per mother: "She's been complaining of a cough, sore throat, and a headache. She has been laying around a
lot more than usual too."
HPI: Patient is a 7-year-old African American female in office with her mother for evaluation of flu-like
symptoms x 1 day. Patient’s mother reports that her fever started last night with a temperature of. Mother
reports patient also has symptoms of a cough, congestion, and body aches. Patient states she is very tired and
presents with lack of energy. She is drinking normally with normal voids. The patient’s mother has given
patient over-the-counter medications, children’s Tylenol and Motrin, at home but symptoms continue to persist.
Medications :
- Children’s Tylenol. Take 12.5 mL every 4 hours by oral route as needed. Do not give more than
5 times in 24 hours.
- Children’s Motrin chewable tablets. Chew 2 ½ tablets every 6 -8 hours by oral route as needed. Do
not use more than 4 times a day
Previous Medical History: No previous medical history
Developmental History:
Allergies: NKDA
Medication Intolerances: No medication intolerances
Chronic Illnesses/Major traumas: No chronic illnesses or major
traumas Immunizations: Immunizations up to date. Refused
COVID/FLU Hospitalizations/Surgeries: No previous 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 include 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
, M: Alive and well. No acute or chronic illnesses reported.
MGM: Alive and well. No acute or chronic illnesses reported.
MGF: Alive and well. No acute or chronic illnesses reported.
F: Alive and well. No acute or chronic illnesses reported.
PGM: Alive and well. No acute or chronic illnesses reported.
PGF: Alive and well. No acute or chronic illnesses reported
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, fatigue, and diminished activity level Cardiovascular: Denial of any chest pain
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Report of coughing and
wheezing
Eyes: Denial of any eye discharge. Denies blurred vision or eye Gastrointestinal: Denial of nausea,
pain vomiting, or diarrhea
Ears: Denial of ear discharge. Denial of any past or current Genitourinary/Gynecological: Denial of
hearing disorders urinary frequency or urgency. Menstrual
cycle not started.
Nose/Mouth/Throat: Report of nasal congestion, sneezing Musculoskeletal: Denial of any joint
runny nose, and sore throat swelling. Reports body aches.
Breast: denial of any pai/tenderness Neurological: Denial of any weakness or
loss of consciousness
Heme/Lymph/Endo: denial of abnormal bleeding or easy Psychiatric: Denial of any symptoms
bruising. No history of blood disorders depression or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 20
66 lbs. 2 oz 4 ft. 4.5 in 16.9 92/64 99.0 128 SPO2%: 96%
General Appearance: Patient is alert and lying down on the examination table. Patient is attentive and can
answer questions when asked.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch
HEENT: Head is normocephalic and atraumatic. PERRLA. Right and left tympanic membrane pearly w/ good
landmarks. Runny nose noted. No crusts/sores to nasal passages. Tonsils enlarged, no exudate noted. Normal
mucous membranes and pharyngeal erythema.
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 96% on room air. Nonproductive cough noted. 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 with tenderness when moving joints
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, Strep testing performed.
Special Tests:
Albuterol Sulfate 2.5 mg/3 ml for inhalation 1 - 3cc vial x 1 treatment given.
Patient was found to have wheezing and coughing requiring handheld nebulizer treatment. Patient tolerated
well. After the treatment, the patient’s symptoms improved significantly.
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) M.R. Date: 03/18/2025 Time: 10:15
Ethnicity: Black/African American Age: 7 Sex: Female
SUBJECTIVE (must complete this section)
CC : Per mother: "She's been complaining of a cough, sore throat, and a headache. She has been laying around a
lot more than usual too."
HPI: Patient is a 7-year-old African American female in office with her mother for evaluation of flu-like
symptoms x 1 day. Patient’s mother reports that her fever started last night with a temperature of. Mother
reports patient also has symptoms of a cough, congestion, and body aches. Patient states she is very tired and
presents with lack of energy. She is drinking normally with normal voids. The patient’s mother has given
patient over-the-counter medications, children’s Tylenol and Motrin, at home but symptoms continue to persist.
Medications :
- Children’s Tylenol. Take 12.5 mL every 4 hours by oral route as needed. Do not give more than
5 times in 24 hours.
- Children’s Motrin chewable tablets. Chew 2 ½ tablets every 6 -8 hours by oral route as needed. Do
not use more than 4 times a day
Previous Medical History: No previous medical history
Developmental History:
Allergies: NKDA
Medication Intolerances: No medication intolerances
Chronic Illnesses/Major traumas: No chronic illnesses or major
traumas Immunizations: Immunizations up to date. Refused
COVID/FLU Hospitalizations/Surgeries: No previous 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 include 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
, M: Alive and well. No acute or chronic illnesses reported.
MGM: Alive and well. No acute or chronic illnesses reported.
MGF: Alive and well. No acute or chronic illnesses reported.
F: Alive and well. No acute or chronic illnesses reported.
PGM: Alive and well. No acute or chronic illnesses reported.
PGF: Alive and well. No acute or chronic illnesses reported
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, fatigue, and diminished activity level Cardiovascular: Denial of any chest pain
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Report of coughing and
wheezing
Eyes: Denial of any eye discharge. Denies blurred vision or eye Gastrointestinal: Denial of nausea,
pain vomiting, or diarrhea
Ears: Denial of ear discharge. Denial of any past or current Genitourinary/Gynecological: Denial of
hearing disorders urinary frequency or urgency. Menstrual
cycle not started.
Nose/Mouth/Throat: Report of nasal congestion, sneezing Musculoskeletal: Denial of any joint
runny nose, and sore throat swelling. Reports body aches.
Breast: denial of any pai/tenderness Neurological: Denial of any weakness or
loss of consciousness
Heme/Lymph/Endo: denial of abnormal bleeding or easy Psychiatric: Denial of any symptoms
bruising. No history of blood disorders depression or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 20
66 lbs. 2 oz 4 ft. 4.5 in 16.9 92/64 99.0 128 SPO2%: 96%
General Appearance: Patient is alert and lying down on the examination table. Patient is attentive and can
answer questions when asked.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch
HEENT: Head is normocephalic and atraumatic. PERRLA. Right and left tympanic membrane pearly w/ good
landmarks. Runny nose noted. No crusts/sores to nasal passages. Tonsils enlarged, no exudate noted. Normal
mucous membranes and pharyngeal erythema.
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 96% on room air. Nonproductive cough noted. 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 with tenderness when moving joints
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, Strep testing performed.
Special Tests:
Albuterol Sulfate 2.5 mg/3 ml for inhalation 1 - 3cc vial x 1 treatment given.
Patient was found to have wheezing and coughing requiring handheld nebulizer treatment. Patient tolerated
well. After the treatment, the patient’s symptoms improved significantly.
