NURS 5337 SOAP Note 3 For FNP CP1 | 2026 Edition | Complete Solutions & Explanations | University of Texas,
Arlington
SOAP Note 3 Form CP1
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
Pat Jones Is an 11 year old male accompanied by mom. She is the primary historian. Maternal Mother
HTN DM and
Paternal father
heart disease and
triple bypass
surgery
Personal/Social
Chief Concern/RFE: Lives with
“He has been having throat pain and fever for 3 days.” mother, father,
and younger
sister who is in 1st
Hx Present Illness: (write in paragraph format) grade
HPI: Patient has had throat pain and fever for 3 days. Mother states a few kids in his class were sick but is unsure of
what they have. Patient’s throat pain is constant and worsening when eating. She has been giving him ibuprofen but
there has not been any relief to his symptoms. She states that he is usually in good health.
CURRENT HEALTH
Medications: children’s ibuprofen; mother follows instructions on back
Allergies:pcn – hives
Last PE & Screenings: none
Immunization Status: not vaccinated for covid-19; is up to date on all other vaccines
LMP & Birth Control (if applicable) n/a
PMH
Illnesses & Trauma: bilateral ear tubes at 2 years old
Hospitalizations/Surgeries: none
OB Hx/Sexual Hx: n/a
Emotional/Psy Hx: n/a
REVIEW OF SYSTEMS
General: fever, acutely ill, able to get sleep at night
Nutrition: adequate PO intake
, Skin/Hair/Nails: no abnormal lesions, masses, rashes
HEENT exudate/pus , red elnlarged tonsil, no abnomalites ears
Breasts n/a
Respiratory denies SOB
CV/peripheral vascular denies heart problems
GI - upset stomach related to illness, no diarrhea or nausea
GU – denies urinary problems
MSK – no weakness or changes in gait
Psych generally well mannered
Neuro – no confusion noted
Lymph/Heme/Endocrine – denies nose bleeds or brusing
O/ Physical Exam: T: 103.3 F orally P: 76/min R: 20/min BP: 102/54 HT: 57 inches WT: 75
lbs / 37.5kg BMI: 16.2 (healthy)
General Patient appears stated age, alert, oriented to person, place & time. Patient is pleasant, and with clear
communication. Good eye contact
Skin Patient skin is tan, no signs of lesions or rashes. Skin temperature is warm.
Head- Head normocephallic, and midline, upright and still
EENT – Eyes: Eyelids symmetric, eye brows and eye lashes evenly distributed, eyeballs firm, conjunctiva clear,
irises brown, lens clear, sclera white, lacrimal apparatus soft, free of erythema or exudate bilaterally, Throat:
exudate/ pus, enlarged tonsils bilaterally; nose: no erythema or drainage, ears: Pinna and lobes nontender bilat, no
nodules or erythema, mastoids nontender without inflammation or masses bilaterally. Canals without erythema or
cerumen, Tympanic membrane pearly gray, no perforations bilaterally, Maxillary and frontal sinuses nontender
bilaterally
Neck- no neck fullness
Breasts/Chest - Chest is tan and warm. Resonance noted throughout lung fields bilaterally
Lungs - – Patient has equal and unlabored respirations. Chest movement and chest rises is equally and
symmetrically. Breath sounds are clear bilaterally, no adventitious breath sounds noted.
Heart/ perip vascular No pulsations, heaves, thrusts or thrill noted. No peripheral edema. Pulse and heart rate has
regular rate and rhythm.
Abdomen No signs of hernia, stomach is rounded, and temperature is warm. No signs of lesion or masses. Patient
with active bowel sounds in all 4 quadrants. Tympany noted in all four quadrants. Abdomen soft and non distended.
Upon light palpation, no tenderness noted
Genitalia/Rectum deferred for this exam
Arlington
SOAP Note 3 Form CP1
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
Pat Jones Is an 11 year old male accompanied by mom. She is the primary historian. Maternal Mother
HTN DM and
Paternal father
heart disease and
triple bypass
surgery
Personal/Social
Chief Concern/RFE: Lives with
“He has been having throat pain and fever for 3 days.” mother, father,
and younger
sister who is in 1st
Hx Present Illness: (write in paragraph format) grade
HPI: Patient has had throat pain and fever for 3 days. Mother states a few kids in his class were sick but is unsure of
what they have. Patient’s throat pain is constant and worsening when eating. She has been giving him ibuprofen but
there has not been any relief to his symptoms. She states that he is usually in good health.
CURRENT HEALTH
Medications: children’s ibuprofen; mother follows instructions on back
Allergies:pcn – hives
Last PE & Screenings: none
Immunization Status: not vaccinated for covid-19; is up to date on all other vaccines
LMP & Birth Control (if applicable) n/a
PMH
Illnesses & Trauma: bilateral ear tubes at 2 years old
Hospitalizations/Surgeries: none
OB Hx/Sexual Hx: n/a
Emotional/Psy Hx: n/a
REVIEW OF SYSTEMS
General: fever, acutely ill, able to get sleep at night
Nutrition: adequate PO intake
, Skin/Hair/Nails: no abnormal lesions, masses, rashes
HEENT exudate/pus , red elnlarged tonsil, no abnomalites ears
Breasts n/a
Respiratory denies SOB
CV/peripheral vascular denies heart problems
GI - upset stomach related to illness, no diarrhea or nausea
GU – denies urinary problems
MSK – no weakness or changes in gait
Psych generally well mannered
Neuro – no confusion noted
Lymph/Heme/Endocrine – denies nose bleeds or brusing
O/ Physical Exam: T: 103.3 F orally P: 76/min R: 20/min BP: 102/54 HT: 57 inches WT: 75
lbs / 37.5kg BMI: 16.2 (healthy)
General Patient appears stated age, alert, oriented to person, place & time. Patient is pleasant, and with clear
communication. Good eye contact
Skin Patient skin is tan, no signs of lesions or rashes. Skin temperature is warm.
Head- Head normocephallic, and midline, upright and still
EENT – Eyes: Eyelids symmetric, eye brows and eye lashes evenly distributed, eyeballs firm, conjunctiva clear,
irises brown, lens clear, sclera white, lacrimal apparatus soft, free of erythema or exudate bilaterally, Throat:
exudate/ pus, enlarged tonsils bilaterally; nose: no erythema or drainage, ears: Pinna and lobes nontender bilat, no
nodules or erythema, mastoids nontender without inflammation or masses bilaterally. Canals without erythema or
cerumen, Tympanic membrane pearly gray, no perforations bilaterally, Maxillary and frontal sinuses nontender
bilaterally
Neck- no neck fullness
Breasts/Chest - Chest is tan and warm. Resonance noted throughout lung fields bilaterally
Lungs - – Patient has equal and unlabored respirations. Chest movement and chest rises is equally and
symmetrically. Breath sounds are clear bilaterally, no adventitious breath sounds noted.
Heart/ perip vascular No pulsations, heaves, thrusts or thrill noted. No peripheral edema. Pulse and heart rate has
regular rate and rhythm.
Abdomen No signs of hernia, stomach is rounded, and temperature is warm. No signs of lesion or masses. Patient
with active bowel sounds in all 4 quadrants. Tympany noted in all four quadrants. Abdomen soft and non distended.
Upon light palpation, no tenderness noted
Genitalia/Rectum deferred for this exam
