Stefani Pierson
Advanced Health Assessment, Summer I 2025
Shadow Health Focused Soap Note Complete Study
Solutions Rated A+ 2025 Update
SUBJECTIVE
CC:
“My throat has been sore and itchy, and my nose won’t stop running. These symptoms are
driving me nuts.”
HPI:
Tina Jones is a 28-year-old African American female presenting with a sore and itchy throat,
runny nose, and itchy, red, watery eyes for the past week. She reports that these symptoms
started spontaneously and have been constant in nature. The throat pain is described as sore
and itchy, with increased discomfort in the morning and when swallowing. She rates her throat
pain as 4/10 and itchiness level 5/10. She has used over-the-counter throat lozenges, which
have provided some relief. The nasal drainage is clear and constant, with no associated
congestion. She has not used any medications for her nasal or eye symptoms. She denies fever,
chills, night sweats, or recent illnesses. She also denies exposure to sick individuals. She believes
her symptoms are due to allergies but has not been introduced to any new allergens.
PMH:
• Asthma since childhood, managed with an albuterol inhaler used 2–3 times a week.
• No known seasonal allergies.
Medications:
• Albuterol inhaler as needed.
Allergies:
• Cats (hay fever symptoms).
Family History:
• Sister with hay fever.
Social History:
• Denies tobacco, alcohol, or illicit drug use.
• No recent travel or exposure to sick contacts.
, Stefani Pierson
Advanced Health Assessment, Summer I 2025
Review of Systems (ROS):
• General: Denies fever, chills, or night sweats.
• HEENT: Sore and itchy throat, runny nose with clear discharge, itchy and watery eyes.
• Respiratory: No cough or shortness of breath.
• Cardiovascular: No chest pain or palpitations.
• Gastrointestinal: No nausea, vomiting, or abdominal pain.
• Neurological: Reports frequent headaches, described as pressurelike, occurring daily
over the past week.
OBJECTIVE
Vital Signs:
• Blood Pressure: 118/76 mmHg
• Heart Rate: 72 bpm
• Respiratory Rate: 16 breaths/min
• Temperature: 98.7°F (37.1°C)
• Oxygen Saturation: 98% on room air Physical Examination:
• General: Alert, well-nourished, and in no acute distress.
• HEENT:
◦ Nasal: Red, irritated nares, pale and bluish nasal mucosa, consistent with allergic
rhinitis.
◦ Oropharynx: Tonsils 1+ (less than 25% of the space between the pillars), with no
exudates or erythema.
◦ Eyes: Conjunctival injection noted; no discharge or visual disturbances reported.
• Skin:
◦ Facial: Excessive facial hair growth and hyperpigmentation on the neck,
suggestive of possible hormonal imbalance.
◦ Acne: Presence of acne on the lateral aspects of the face.
• Neurological: Cranial nerves II–XII intact; no focal deficits observed.
• Ophthalmologic: Fundoscopic examination reveals cotton wool spots in the right retina,
indicating possible retinal ischemia.
ASSESSMENT Problem List:
1. Acute Rhinosinusitis Symptoms (sore throat, runny nose, itchy/watery eyes, headache) -
primary focus
2. Asthma, well-controlled
3. Possible Hormonal Imbalance (hirsutism, acanthosis nigricans, acne)
Advanced Health Assessment, Summer I 2025
Shadow Health Focused Soap Note Complete Study
Solutions Rated A+ 2025 Update
SUBJECTIVE
CC:
“My throat has been sore and itchy, and my nose won’t stop running. These symptoms are
driving me nuts.”
HPI:
Tina Jones is a 28-year-old African American female presenting with a sore and itchy throat,
runny nose, and itchy, red, watery eyes for the past week. She reports that these symptoms
started spontaneously and have been constant in nature. The throat pain is described as sore
and itchy, with increased discomfort in the morning and when swallowing. She rates her throat
pain as 4/10 and itchiness level 5/10. She has used over-the-counter throat lozenges, which
have provided some relief. The nasal drainage is clear and constant, with no associated
congestion. She has not used any medications for her nasal or eye symptoms. She denies fever,
chills, night sweats, or recent illnesses. She also denies exposure to sick individuals. She believes
her symptoms are due to allergies but has not been introduced to any new allergens.
PMH:
• Asthma since childhood, managed with an albuterol inhaler used 2–3 times a week.
• No known seasonal allergies.
Medications:
• Albuterol inhaler as needed.
Allergies:
• Cats (hay fever symptoms).
Family History:
• Sister with hay fever.
Social History:
• Denies tobacco, alcohol, or illicit drug use.
• No recent travel or exposure to sick contacts.
, Stefani Pierson
Advanced Health Assessment, Summer I 2025
Review of Systems (ROS):
• General: Denies fever, chills, or night sweats.
• HEENT: Sore and itchy throat, runny nose with clear discharge, itchy and watery eyes.
• Respiratory: No cough or shortness of breath.
• Cardiovascular: No chest pain or palpitations.
• Gastrointestinal: No nausea, vomiting, or abdominal pain.
• Neurological: Reports frequent headaches, described as pressurelike, occurring daily
over the past week.
OBJECTIVE
Vital Signs:
• Blood Pressure: 118/76 mmHg
• Heart Rate: 72 bpm
• Respiratory Rate: 16 breaths/min
• Temperature: 98.7°F (37.1°C)
• Oxygen Saturation: 98% on room air Physical Examination:
• General: Alert, well-nourished, and in no acute distress.
• HEENT:
◦ Nasal: Red, irritated nares, pale and bluish nasal mucosa, consistent with allergic
rhinitis.
◦ Oropharynx: Tonsils 1+ (less than 25% of the space between the pillars), with no
exudates or erythema.
◦ Eyes: Conjunctival injection noted; no discharge or visual disturbances reported.
• Skin:
◦ Facial: Excessive facial hair growth and hyperpigmentation on the neck,
suggestive of possible hormonal imbalance.
◦ Acne: Presence of acne on the lateral aspects of the face.
• Neurological: Cranial nerves II–XII intact; no focal deficits observed.
• Ophthalmologic: Fundoscopic examination reveals cotton wool spots in the right retina,
indicating possible retinal ischemia.
ASSESSMENT Problem List:
1. Acute Rhinosinusitis Symptoms (sore throat, runny nose, itchy/watery eyes, headache) -
primary focus
2. Asthma, well-controlled
3. Possible Hormonal Imbalance (hirsutism, acanthosis nigricans, acne)
