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. Episodic/Focused SOAP Note Template Examples.
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?
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? Episodic/Focused SOAP Note Template Examples.
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 Episodic/Focused SOAP Note Template Examples
Father: age 63, has Arthritis, and HTN
Siblings: She has 2 sisters age 18 and 16. Both are alive and well, no health conditions reported
Review of Systems:
GENERAL: The patient is awake, alert, oriented and appears generally well. See HPI.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. No decreased hearing. No hearing loss, sneezing, or congestion. Has complaints of runny nose, sore throat, headaches, and hoarse voice.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Respirations are regular and unlabored. No shortness of breath, cough or sputum.
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