NURS 6512 Week 5 Episodic/Focused

SOAP Note Template

Patient Information:

L., 20, F, Caucasian

SUBJECTIVE.

CC: “I have been having sore throat for three days, and I also have decreased appetite, headache,

and pain with swallowing.”

HPI: Ms. L is a 20-year-old female college student who presents with sore throat for three days,

with additional decreased appetite, headache, and pain with swallowing. She recounts that

similar “flu-like” symptoms recently affecting multiple students on campus. Ms. L also noted

runny nose and a slight hoarseness in her voice but doesn't sound congested. She took Tylenol

and Chloraseptic lozenges, but did little for relief.

Location: throat

Onset: 3 days ago

Character: throat is sore

Associated signs and symptoms: decreased appetite, headache, and pain with

swallowing.

Timing: constant

Exacerbating/ relieving factors: light bothers eyes, Tylenol makes it tolerable but not

completely better.

Severity: 8/10 pain scale

Problem-Specific Questions:

Have you been coughing? Any drainage or phlegm? Is it productive, if so how much?

What is the color of the phlegm?

Have you been running a fever or exhibiting chills?

Are you taking any medications for this? Are they helping?

Are you having any pain or pressure in your face, head, or sinuses? Have you recently

had a head injury? Any nasal bleeding noted?

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Do you smoke or have you been around anyone who smokes?

Do you experience gastroesophageal reflux or heartburn?

Does it hurt to swallow solids, liquids, or both?

Do you feel like something is stuck in your throat?

Do you cough or choke when swallowing?

Do you have any changes in your appetite? Did it start with the onset of your sore throat?

Any changes in your weight? Did you lose or gain weight?

What have you eaten in the last twenty-four hours?

Have you had any nausea or vomiting?

Current Medications: Multivitamins 1 tablet daily; and Blisovi Fe 1/20 1 tab daily

Allergies: Penicillin (Hives)

PMHx: No pertinent medical history reported, it is unremarkable. No recent hospitalizations

reported in the past. Immunizations are current. Last tetanus shot was taken June 2010. Last flu

shot was taken September 2016. Denies any history of accidents/injury or falls.

Soc Hx: Ms. L was born in Galveston, TX, and currently attends a community college at

Houston Community College – Katy Campus. She attends classes Mon-Fri from 8am to 3pm.

She works at daycare center on the weekends while in school, and during the week on Summer

break. She is Single, and heterosexual. She is in a monogamous relationship with her boyfriend,

and sexually active. She exercises 3x/week, and eats a diet consisting of meat/fish, vegetables,

fruits, rice and beans. She drives a vehicle, and always put on her seatbelt. She is a social drinker,

takes 1-2 glasses of wine every 2 weeks. Never smoked, and denies use of illicit/recreational

drugs. Drinks green tea daily.

Fam Hx:

Maternal Grandmother: deceased at age 83 related to Stroke

Maternal Grandfather: deceased at age 98, no health conditions noted

Paternal Grandmother: deceased at age 38, post-partum hemorrhage

Paternal Grandfather: deceased at age 102 related to uncontrolled HTN

Mother: age 57, No health conditions reported

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