Week 3 Episodic SOAP Note #1

Patient Information:

A.A., 20, Female, Caucasian

S.

CC: Sore throat, flu-like symptoms

HPI:

20-year-old college student presents to office complaining of sore throat, pain with

swallowing, decreased appetite, headaches, runny nose and a slight hoarseness in her throat.

Patient states her symptoms began approximately 3 days ago and denies any congestion in her

voice. Patient admits that she is aware of flu-like symptoms have been “going around” at her

campus.

Current Medications: self-medicated with Tylenol for headaches as needed.

Allergies: negative for any allergies to food and drugs

PMHx: Updated immunization status for TDAP, Flu vaccine

Soc Hx: Negative for tobacco abuse, alcohol consumption and use of illicit drugs. Patient is in

college and a a heterosexual single female who dates casually and practices safe sex using birth

control and condoms.

Fam Hx: Mother is age 55 with no PMH and Father is age 57 who is a prostate cancer survivor.

Patient denies diabetes, cardiovascular disease and stroke in her first-degree relatives.

ROS:

GENERAL: Positive for fatigue; negative for weakness, fever, no significant weight change.

HEENT: Positive for headache, runny nose, hoarseness; negative for head injury, dizziness,

lightheadedness, vision changes, hearing problems, tinnitus, vertigo, earaches, nosebleeds, sinus

trouble, and dry mouth.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or

edema.

RESPIRATORY: Negative for cough, sputum, hemoptysis, dyspnea, wheezing.

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