SOAP Notes Sample
PATIENT NAME: Ms. Brown
DATE OF BIRTH: 28/02/1987
CHIEF COMPLAINT: The patient has a sore throat
HPI-ROS:
SUBJECTIVE: The patient came into ED for a sore throat lasting for 5 days now. Her neck is swollen and she expresses difficulty in swallowing. She had a fever for a couple of days but was not measured.
The patient narrates that she has been to a party with friends and family that were sick before. She shared a drink with her friend who had been sick but was getting better a few days before the onset of the sore throat.
The patient has seen a doctor since then and she was treated for strep. She was given amoxicillin to treat her strep but she is not feeling better. Her throat is worse and she noticed a rash on her abdomen that does not itch, a couple of days after taking the medicine. Her stomach hurts on the left side. There is no cough, no nausea, no vomiting, no bowel symptoms, no urinary symptoms, no leg pain or swelling. She is feeling a little light-headed. There has been no history of major illness or abdominal surgery.
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REVIEW OF SYSTEMS:
General: Generally in good health, there has been no change in strength or endurance.
Head: There were no headaches, dizziness, or pain.
Eyes: There was no diplopia, tearing, no scotoma, and no pain in the eyes.
Ears: There was no change in hearing, tinnitus, bleeding, or vertigo.
Nose: Epistaxis, coryza, blockage, and discharge are all absent.
Mouth: Three days with a sore throat.
Neck: Swollen Neck, Patient expresses difficulty swallowing, no stiffness
Chest: There was no coughing, no wheezing, no hemoptysis, and no dyspnea.
Integumentary System: An abdomino-pelvic rash that is not itchy.
Heart: Not a single sign of any of the above symptoms.
Abdomen: The left side of my stomach aches.
GU: Urinary urgency, dysuria, or a change in the consistency or color of the urine are not present.
Musculoskeletal: No aches or pains in the muscles or joints, no restrictions on movement, and no numbness or paresthesia’s.
Neurologic: There were no signs of fatigue, tremor, convulsions, altered cognition, or ataxia.
Psychiatric: There are no signs of depression, no shifts in sleep patterns, and no shifts in the substance of one's thoughts.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.
OBJECTIVE:
General: Patient is awake, alert, and oriented, very friendly, has no acute distress or whatsoever.
HEENT: Parietal erythema with bilateral exudates, hypertrophic tonsils, slight trismus, anterior submandibular adenopathy, posterior cervical adenopathy, neck supple, nose clear, dry mucus membrane, mild dysphonia.
Heart: tachycardia with s4 gallop, ⅙ murmurs, or rubs.
Chest: Auscultation of the lungs reveals no abnormalities on either side. You won't hear any rales or wheezes.
Abdomen: The spleen is roughly a fingerbreadth below the left costal border.
Integumentary: Her lower legs and belly were covered with a tiny, macular rash.
Extremities: Not much swelling. The ability to move freely. The calf is not sensitive.
PLAN: Patient began with 1L of normal saline solution. Starting with CBC, basic metabolic panel, and mono spot test, these are the labs you should go to first. Abdominal ultrasound with emphasis to the left upper quadrant for potential splenomegaly, and a urine test.
RISK FACTORS
The inhalation of secondhand smoke.
Allergies.
Chemical irritant exposure is a health risk.
Close proximity.
Immunity is compromised.
