CONPH NSG6435 Subjective, Objective, Assessment, Plan
Student Name: (SOAP) Notes Course: NSG6435
Patient Name: (Initials ONLY) B.F. Date: 10/30/23 Time:0800
Ethnicity: White Age: 13 Sex: M
SUBJECTIVE (must complete this section)
CC: Patient presents for routine well-child check
HPI: B.F. is a 13-year-old boy presenting for annual well child check in no acute condition. He is accompanied by his
mother. He has a history of intermittent headaches, for which he takes rizatriptan 5 mg, as needed. The headaches occur in
the frontal region roughly every other day accompanied by nausea; no aura. He has no other concerns at this time.
Medications: Rizatriptan 5 mg tablet, PRN for acute migraines; Epinephrine 0.3 mg/ml injection, auto-injector for allergic
reaction as needed
Previous Medical History: Migraines since 2020
Developmental History: No developmental deficits
Allergies: Peanuts
Medication Intolerances: NKDA
Chronic Illnesses/Major traumas: None
Immunizations: Up-to-date per Georgia Immunization Registry (GRITS)
Hospitalizations/Surgeries: N/A
Health Promotion/Health Maintenance: Encouraged daily exercise and limiting screen time.
Nutrition/Diet: Adequate; encouraged increasing fruit and vegetable intake.
Exercise/Regimen: Plays competitive soccer
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: None
Safety Measures: Always wears a seatbelt
Screening exams: HEADSS Assessment
FAMILY HISTORY (must complete this section)
M: aged 40; healthy
MGM: alive
MGF: alive
F: aged 42; HTN. Lives in Indiana. Step-father died in 2020 in an auto accident.
PGM: alive
PGF: alive
Social History: 7th grader at Richmond Hill Middle School
REVIEW OF SYSTEMS (must complete this section)
General: Denies fever or chills. Cardiovascular: No chest pain or palpitations.
Skin: Denies rash or new skin lesions. Respiratory: Denies shortness of breath, coughing, or
wheezing.
Eyes: No changes in vision. Gastrointestinal: Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain.
Ears: Denies ear pain, hearing loss, ringing in ears, or Genitourinary/Gynecological: No urgency, frequency,
discharge. nocturia, or pain with urination.
Nose/Mouth/Throat: No nasal drainage, congestion, sore Musculoskeletal: No muscle weakness, joint swelling or
throat. stiffness.
Breast: N/A Neurological: Admits migraines without aura. No seizures
or syncope. No paresthesia, tremors, or weakness.
Heme/Lymph/Endo: No polydipsia or polyuria. Weight and Psychiatric: Denies anxiety, depression, or suicidal
appetite stable. No cold or heat intolerance. No bruising or ideation/attempts.
abnormal bleeding. No history of anemia. No
lymphadenopathy.
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
BP: Pulse: Resp: 98
Weight: Height: BMI: 115/66 Temp: 80
85 lbs. 60" 16.7 98F SPO2%: 98
General Appearance: Healthy appearing youth in no acute distress; Well-nourished, normal BMI.
Skin:
HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA, EOMI. No
conjunctival redness or inflammation. Ears: Canals patent. Bilateral TMs normal color with distinct landmarks. Nose:
Nasal mucosa pink; normal turbinates. Neck: No masses, lymphadenopathy, or thyroid abnormality. Oral mucosa pink
and moist, no lesions noted.ad is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA,
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Student Name: (SOAP) Notes Course: NSG6435
Patient Name: (Initials ONLY) B.F. Date: 10/30/23 Time:0800
Ethnicity: White Age: 13 Sex: M
SUBJECTIVE (must complete this section)
CC: Patient presents for routine well-child check
HPI: B.F. is a 13-year-old boy presenting for annual well child check in no acute condition. He is accompanied by his
mother. He has a history of intermittent headaches, for which he takes rizatriptan 5 mg, as needed. The headaches occur in
the frontal region roughly every other day accompanied by nausea; no aura. He has no other concerns at this time.
Medications: Rizatriptan 5 mg tablet, PRN for acute migraines; Epinephrine 0.3 mg/ml injection, auto-injector for allergic
reaction as needed
Previous Medical History: Migraines since 2020
Developmental History: No developmental deficits
Allergies: Peanuts
Medication Intolerances: NKDA
Chronic Illnesses/Major traumas: None
Immunizations: Up-to-date per Georgia Immunization Registry (GRITS)
Hospitalizations/Surgeries: N/A
Health Promotion/Health Maintenance: Encouraged daily exercise and limiting screen time.
Nutrition/Diet: Adequate; encouraged increasing fruit and vegetable intake.
Exercise/Regimen: Plays competitive soccer
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: None
Safety Measures: Always wears a seatbelt
Screening exams: HEADSS Assessment
FAMILY HISTORY (must complete this section)
M: aged 40; healthy
MGM: alive
MGF: alive
F: aged 42; HTN. Lives in Indiana. Step-father died in 2020 in an auto accident.
PGM: alive
PGF: alive
Social History: 7th grader at Richmond Hill Middle School
REVIEW OF SYSTEMS (must complete this section)
General: Denies fever or chills. Cardiovascular: No chest pain or palpitations.
Skin: Denies rash or new skin lesions. Respiratory: Denies shortness of breath, coughing, or
wheezing.
Eyes: No changes in vision. Gastrointestinal: Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain.
Ears: Denies ear pain, hearing loss, ringing in ears, or Genitourinary/Gynecological: No urgency, frequency,
discharge. nocturia, or pain with urination.
Nose/Mouth/Throat: No nasal drainage, congestion, sore Musculoskeletal: No muscle weakness, joint swelling or
throat. stiffness.
Breast: N/A Neurological: Admits migraines without aura. No seizures
or syncope. No paresthesia, tremors, or weakness.
Heme/Lymph/Endo: No polydipsia or polyuria. Weight and Psychiatric: Denies anxiety, depression, or suicidal
appetite stable. No cold or heat intolerance. No bruising or ideation/attempts.
abnormal bleeding. No history of anemia. No
lymphadenopathy.
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
BP: Pulse: Resp: 98
Weight: Height: BMI: 115/66 Temp: 80
85 lbs. 60" 16.7 98F SPO2%: 98
General Appearance: Healthy appearing youth in no acute distress; Well-nourished, normal BMI.
Skin:
HEENT: Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA, EOMI. No
conjunctival redness or inflammation. Ears: Canals patent. Bilateral TMs normal color with distinct landmarks. Nose:
Nasal mucosa pink; normal turbinates. Neck: No masses, lymphadenopathy, or thyroid abnormality. Oral mucosa pink
and moist, no lesions noted.ad is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA,
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