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
... [Show More] 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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GASTROINTESTINAL: Positive for difficulty swallowing, decreased appetite. Negative for
heartburn, nausea, vomiting, diarrhea, rectal bleeding or tarry stools, constipation, abdominal
pain, food intolerance.
GENITOURINARY: Denies any GU issues. Last menstrual period, 03/01/2019.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in
the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: negative for muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No history of anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: negative for depression or anxiety.
ENDOCRINOLOGIC: negative for sweating, cold or heat intolerance. negative for polyuria or
polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
VS: BP 106/62; P 94; R 18; T 97.8; 02 99% Wt 118lbs; Ht 54”
Physical exam:
General: Alert and oriented x 4, no apparent distress, normal level of consciousness, good
personal hygiene.
HEENT: Positive for erythema of throat, exudate of throat. No gross deformity, sclerae anicteric,
normal conjuctivae, PERRLA, no sinus tenderness, no boggy nasal mucosa, no lesions of the
throat, no enlargement of tonsils, tympanic membrane clear.
ABDOMEN: Soft, non-tender, no surgical scars, no trauma on inspection, normal bowel sounds
x 4, no masses noted on light or deep palpation, no hepatosplenomegaly, no rebound tenderness.
LUNGS: Lungs are clear to auscultation and percussion bilaterally, no adventitious breath
sounds.
Diagnostic results:
Rapid strep test- negative
throat culture- negative
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