SOAP Note 1 Week 4

Instructions for Completing the SOAP Note

1. Review the SOAP note resources provided in the course content.

2. Read the Case Study: Begin by carefully reading the case study provided below. Pay close attention to the patient’s background, medical history, and presenting complaint.

3. Download the SOAP Form: Access the attached SOAP form. This form will serve as your template for documenting the patient encounter.

4. Complete the SOAP Form: Using the information from the case study, fill out the SOAP form to the best of your ability. Ensure that you provide details for each section: Subjective, Objective, Assessment, and Plan. Any part of the assessment not mentioned in the case study is considered normal.

5. Thoroughness is Key: Aim to complete each section of the SOAP form as comprehensively as possible. Include relevant information obtained from both the patient’s subjective account and objective observations.

6. Submit Your Completed SOAP Note: Once you have filled out the SOAP form, submit your completed document according to the instructions provided by your instructor. Include at least 2 reference.

CASE STUDY: Fever, Sore Throat, Fatigue

History

A.J. is a previously healthy 17-year-old female who presents to her primary care office due to fever, sore throat, fatigue, and cervical lymphadenopathy. Symptoms started 5 days ago and have been increasingly worse. She has been taking ibuprofen 200 mg every 6 to 8 hours which she states improves the fever and sore throat. She rates her current pain as 8/10. She reports that her brother had similar symptoms about 1 month ago. She denies weight loss, night sweats, other sites of lymph node enlargement, cough, rhinorrhea, abdominal pain, diarrhea, constipation, or rash. She has allergic rhinitis and takes Loratidine 10 mg PO daily. She has no drug allergies. She had a tonsillectomy at age 8. She has no significant family history. She denies smoking, recent travel, exposure to cats, or IV drug use. She is not sexually active and denies ever having intercourse. She is a high school student who is currently running track. She has had to miss practice due to illness.

Physical Examination

She appears ill. Her temperature is 101.8°F (38.7°C). Her pulse is 93 and her respirations are 18. Her weight is stable based on her previous visit. On physical examination, the clinician finds anterior cervical, posterior cervical, and axillary lymphadenopathy. Lymph nodes are bilateral, soft, mobile, and tender to palpation. The size of lymph nodes is estimated at 8 to 10 mm. She has no other superficial lymphadenopathy or splenomegaly on examination. Her posterior pharynx is erythematous without exudate. Tonsils are surgically removed. Her skin is clean, dry, and intact without any rashes, abrasions, or signs of infections. Heart rate and rhythm are regular and lungs are clear to auscultation bilaterally.