Student: N. Byrd, MSN student
Widener Dwyer School of Nursing
AGACNP PROGRAM Date: 6/22/2026
Clinical Site: TUH Med-Surg unit
SOAP NOTE Preceptor: Dr. Shahnaz Duymun
Purpose: This framework guides clinical reasoning and documentation.
S — SUBJECTIVE
Chief Complaint (CC) — patient's own words, quoted
"I got bit by a stray dog while trying to protect my dog."
History of Present Illness (HPI) —
23-year-old male with a PMH significant for anxiety presents to the emergency department
after sustaining a dog bite to his left hand earlier today. The patient reports that he was walking
his dog when a stray dog approached aggressively and attempted to attack his pet. To protect
his dog, he intervened and was bitten by the stray animal. He reports immediate pain and
bleeding from the wound site.
Since the injury occurred, he has noted persistent pain and mild swelling around the bite area.
He rates his pain as 7/10 in severity. The patient denies numbness, tingling, weakness, loss of
sensation, decreased range of motion, fever, chills, nausea, vomiting, or other traumatic
injuries.
He reports that the stray dog fled the scene, and he is unable to provide information regarding
the animal's vaccination status. He states that his symptoms have remained unchanged since
onset. He denies aggravating or relieving factors. The patient reports that his last tetanus
vaccination was approximately five years ago.
Pertinent Past Medical & Surgical History
Anxiety disorder
Medications — include dose, route, frequency
Sertraline 25 mg, PO daily
Allergies & Reactions
No known drug allergies
Social History — tobacco, alcohol, substance use, living situation, occupation, support system
23 y/o male employed full-time as personal trainer, denies as ETOH or substance use, denies
smoking history; independent with ADLs and lives home with both parents
Family History — relevant to presenting problem
AGACNP Program | SOAP Note Clinical Framework | For Academic Use Only
, N/A
Review of Systems (ROS) —
Constitutional
denies fever, chills, fatigue, or weight loss.
Cardiovascular
denies chest pain, palpitations, or syncope.
Pulmonary
Denies shortness of breath, cough, or wheezing.
Gastrointestinal
Denies abdominal pain, nausea, vomiting, diarrhea, or constipation.
Genitourinary
Denies dysuria, hematuria, or urinary symptoms.
Neurological
Denies headache, dizziness, weakness, numbness, or tingling
Musculoskeletal
Reports pain and swelling at the left hand bite site. Denies decreased range of motion.
Skin
Reports dog bite wound to the left hand with mild swelling.
Psychiatric
Reports history of anxiety. Denies suicidal ideation, homicidal ideation, panic attacks, or acute
psychiatric symptoms
O — OBJECTIVE
Vital Signs — include ALL available; note trends if serial
BP (mmHg) HR (bpm) RR (/min) Temp (°F/°C) SpO₂ (%) Weight (kg) Pain (0–10)
AGACNP Program | SOAP Note Clinical Framework | For Academic Use Only
Widener Dwyer School of Nursing
AGACNP PROGRAM Date: 6/22/2026
Clinical Site: TUH Med-Surg unit
SOAP NOTE Preceptor: Dr. Shahnaz Duymun
Purpose: This framework guides clinical reasoning and documentation.
S — SUBJECTIVE
Chief Complaint (CC) — patient's own words, quoted
"I got bit by a stray dog while trying to protect my dog."
History of Present Illness (HPI) —
23-year-old male with a PMH significant for anxiety presents to the emergency department
after sustaining a dog bite to his left hand earlier today. The patient reports that he was walking
his dog when a stray dog approached aggressively and attempted to attack his pet. To protect
his dog, he intervened and was bitten by the stray animal. He reports immediate pain and
bleeding from the wound site.
Since the injury occurred, he has noted persistent pain and mild swelling around the bite area.
He rates his pain as 7/10 in severity. The patient denies numbness, tingling, weakness, loss of
sensation, decreased range of motion, fever, chills, nausea, vomiting, or other traumatic
injuries.
He reports that the stray dog fled the scene, and he is unable to provide information regarding
the animal's vaccination status. He states that his symptoms have remained unchanged since
onset. He denies aggravating or relieving factors. The patient reports that his last tetanus
vaccination was approximately five years ago.
Pertinent Past Medical & Surgical History
Anxiety disorder
Medications — include dose, route, frequency
Sertraline 25 mg, PO daily
Allergies & Reactions
No known drug allergies
Social History — tobacco, alcohol, substance use, living situation, occupation, support system
23 y/o male employed full-time as personal trainer, denies as ETOH or substance use, denies
smoking history; independent with ADLs and lives home with both parents
Family History — relevant to presenting problem
AGACNP Program | SOAP Note Clinical Framework | For Academic Use Only
, N/A
Review of Systems (ROS) —
Constitutional
denies fever, chills, fatigue, or weight loss.
Cardiovascular
denies chest pain, palpitations, or syncope.
Pulmonary
Denies shortness of breath, cough, or wheezing.
Gastrointestinal
Denies abdominal pain, nausea, vomiting, diarrhea, or constipation.
Genitourinary
Denies dysuria, hematuria, or urinary symptoms.
Neurological
Denies headache, dizziness, weakness, numbness, or tingling
Musculoskeletal
Reports pain and swelling at the left hand bite site. Denies decreased range of motion.
Skin
Reports dog bite wound to the left hand with mild swelling.
Psychiatric
Reports history of anxiety. Denies suicidal ideation, homicidal ideation, panic attacks, or acute
psychiatric symptoms
O — OBJECTIVE
Vital Signs — include ALL available; note trends if serial
BP (mmHg) HR (bpm) RR (/min) Temp (°F/°C) SpO₂ (%) Weight (kg) Pain (0–10)
AGACNP Program | SOAP Note Clinical Framework | For Academic Use Only
