iHuman Jenna James (Amanda Wheaton) Case Study |
23-Year-Old with Sore Throat |SOAP Note, Different
EXAM
| **Name** | Jenna James (Amanda Wheaton) |
| **Age** | 23 years |
| **Sex** | Female |
| **Height** | 5'7" (170 cm) |
| **Weight** | 120 lbs (54.5 kg) |
| **BMI** | 18.8 (Normal) |
| **Occupation** | Law Student |
| **Living Situation** | Lives with roommates in an off-campus apartment |
, | **Setting** | Outpatient Student Health/Primary Care Clinic |
---
## SOAP Note
### S - Subjective
**Chief Complaint (CC):**
"My throat is very sore and it hurts to swallow."
**History of Present Illness (HPI):**
Jenna James is a generally healthy 23-year-old female who presents to the
student health clinic with a chief complaint of a sore throat and fever that began
2-3 days ago. The sore throat came on suddenly and has progressively worsened.
She describes the pain as sharp, constant, and **"like an ice pick"**. The pain is
exacerbated by swallowing (**odynophagia**) and talking, which has significantly
restricted her oral intake to cold liquids only.
Associated symptoms include subjective fever, chills, headache, fatigue, malaise,
and mild body aches. She also reports bilateral, tender swelling in her neck. She
has been taking over-the-counter acetaminophen (Tylenol) with minimal relief.
**Review of Systems (ROS):**
* **General:** Fever, chills, fatigue, malaise, decreased appetite.
23-Year-Old with Sore Throat |SOAP Note, Different
EXAM
| **Name** | Jenna James (Amanda Wheaton) |
| **Age** | 23 years |
| **Sex** | Female |
| **Height** | 5'7" (170 cm) |
| **Weight** | 120 lbs (54.5 kg) |
| **BMI** | 18.8 (Normal) |
| **Occupation** | Law Student |
| **Living Situation** | Lives with roommates in an off-campus apartment |
, | **Setting** | Outpatient Student Health/Primary Care Clinic |
---
## SOAP Note
### S - Subjective
**Chief Complaint (CC):**
"My throat is very sore and it hurts to swallow."
**History of Present Illness (HPI):**
Jenna James is a generally healthy 23-year-old female who presents to the
student health clinic with a chief complaint of a sore throat and fever that began
2-3 days ago. The sore throat came on suddenly and has progressively worsened.
She describes the pain as sharp, constant, and **"like an ice pick"**. The pain is
exacerbated by swallowing (**odynophagia**) and talking, which has significantly
restricted her oral intake to cold liquids only.
Associated symptoms include subjective fever, chills, headache, fatigue, malaise,
and mild body aches. She also reports bilateral, tender swelling in her neck. She
has been taking over-the-counter acetaminophen (Tylenol) with minimal relief.
**Review of Systems (ROS):**
* **General:** Fever, chills, fatigue, malaise, decreased appetite.
