SOAP Note _Week 6 Name:____Amanda Bright
Typhon Encounter #: _____________________
NU__610_:_________ Comprehensive:____Focused:____
Herzing University
S: SUBJECTIVE DATA
CC: “My son has been coughing and now complains of ear pain.” – mother.
HPI: Patient presents today with a dry cough and right ear pain onset approximately 3
days ago. And also complains of a cough that is continuously and worsening at
night. It is a dry cough. No fevers noted, but is slightly. Higher body temperature.
He has been taking Tylenol. As needed. He is still active but increased irritability
PMH: 6 year old healthy boy, no known medical issues, was born full term. No prior
hospitalizations known
ALLERGIES NKDA
MEDICATIONS Acetaminophen 160 mg PO as needed
SH Lives with parents, attends school, no tobacco or vaping exposure at home, good
nutrition, up to date on vaccines
FH Non-contributory; no family history of chronic lung disease or ear infections
HEALTH PROMOTION & Immunizations: Up to date per CDC schedule, including DTaP, IPV,
MAINTENANCE MMR, Varicella, Influenza, COVID-19, and Hepatitis A series (catch-up
if needed)
Diet: Balanced nutrition with fruits, vegetables, and adequate hydration;
limit sugary snacks and drinks
Exercise: At least 60 minutes of physical activity daily
Sleep: 9–12 hours per night recommended for age 6; maintain consistent
bedtime routines
Dental Care: Routine dental visits every 6 months; use fluoride toothpaste
Vision & Hearing: Routine screening at school entry; monitor for changes
in vision or hearing
Safety: Age-appropriate car seat or booster use, helmet use for biking,
handwashing, avoiding secondhand smoke
Behavioral & Social Health: Monitor social interactions, school
performance, and emotional well-being; encourage communication about
feelings
Family & Environmental Factors: Ensure safe home environment; avoid
exposure to tobacco, vaping, or environmental hazards
ROS Constitutional No fever initially; today mild fever
99.8°F
(put N/A in sections not N/A
Head
completed day of exam)
Eyes N/A
Ears, Nose, Mouth, Throat Nose, Mouth, Throat: Mild throat
irritation, nasal congestion, right ear
pain
Neck No swelling or stiffness
Cardiovascular/Peripheral Regular rate and rhythm, no murmurs,
Vascular no cyanosis, no edema
Typhon Encounter #: _____________________
NU__610_:_________ Comprehensive:____Focused:____
Herzing University
S: SUBJECTIVE DATA
CC: “My son has been coughing and now complains of ear pain.” – mother.
HPI: Patient presents today with a dry cough and right ear pain onset approximately 3
days ago. And also complains of a cough that is continuously and worsening at
night. It is a dry cough. No fevers noted, but is slightly. Higher body temperature.
He has been taking Tylenol. As needed. He is still active but increased irritability
PMH: 6 year old healthy boy, no known medical issues, was born full term. No prior
hospitalizations known
ALLERGIES NKDA
MEDICATIONS Acetaminophen 160 mg PO as needed
SH Lives with parents, attends school, no tobacco or vaping exposure at home, good
nutrition, up to date on vaccines
FH Non-contributory; no family history of chronic lung disease or ear infections
HEALTH PROMOTION & Immunizations: Up to date per CDC schedule, including DTaP, IPV,
MAINTENANCE MMR, Varicella, Influenza, COVID-19, and Hepatitis A series (catch-up
if needed)
Diet: Balanced nutrition with fruits, vegetables, and adequate hydration;
limit sugary snacks and drinks
Exercise: At least 60 minutes of physical activity daily
Sleep: 9–12 hours per night recommended for age 6; maintain consistent
bedtime routines
Dental Care: Routine dental visits every 6 months; use fluoride toothpaste
Vision & Hearing: Routine screening at school entry; monitor for changes
in vision or hearing
Safety: Age-appropriate car seat or booster use, helmet use for biking,
handwashing, avoiding secondhand smoke
Behavioral & Social Health: Monitor social interactions, school
performance, and emotional well-being; encourage communication about
feelings
Family & Environmental Factors: Ensure safe home environment; avoid
exposure to tobacco, vaping, or environmental hazards
ROS Constitutional No fever initially; today mild fever
99.8°F
(put N/A in sections not N/A
Head
completed day of exam)
Eyes N/A
Ears, Nose, Mouth, Throat Nose, Mouth, Throat: Mild throat
irritation, nasal congestion, right ear
pain
Neck No swelling or stiffness
Cardiovascular/Peripheral Regular rate and rhythm, no murmurs,
Vascular no cyanosis, no edema
