Student Name: Brougan Sheets
Course:625 L
Date: 12/04/24
Practicum Comprehensive SOAP Note
CC Sore throat for 2 days and fever
S HPI 8-year-old male presents with is mother today, who provides the
history. She reports that he has had a sore throat for the past 2 days
and a fever with a high of 101F.
The patient reports that the sore throat started 2 days ago and has
progressively worsened. He describes the pain as sharp and
constant, especially when swallowing. The pain is localized in the
throat and has not radiated to the ears. He has difficulty
swallowing food but is able to drink fluids, although this is also
somewhat painful.
Associated symptoms include fever (up to 101°F), headache, and
mild fatigue. No cough, nasal congestion, or diarrhea. Denies
abdominal pain or vomiting.
Denies any recent exposure to sick contacts.
Current/PMH No current or previous medical history
Surgical Hx No surgical history
Medications
None
Allergies No known drug allergies
No known seasonal allergies
No known food allergies
Family Hx Non-contributory: no history of autoimmune disorders, chronic
illnesses, or significant infections in immediate family members
Social Hx -Lives with both parents and two siblings in a non-smoking
household.
-Attends school regularly and participates in age-appropriate
activities such as soccer and swimming.
-No exposure to second-hand smoke or environmental toxins.
ROS Constitutional: Fever, fatigue, no weight loss or night sweats.
HEENT: Sore throat, no nasal congestion, no ear pain, no
rhinorrhea, no mouth ulcers.
Cardiovascular: No chest pain, no palpitations.
Respiratory: No cough, no shortness of breath, no wheezing.
GI: No abdominal pain, nausea, vomiting, or diarrhea.
Genitourinary: No dysuria or hematuria.
Musculoskeletal: No joint pain, swelling, or stiffness.
Neurologic: No headaches, dizziness, or loss of consciousness.
This study source was downloaded by 100000900934077 from CourseHero.com on 09-08-2025 18:30:02 GMT -05:00
https://www.coursehero.com/file/246170568/SOAP-Note-Week-5docx/
, Student Name: Brougan Sheets
Course:625 L
Date: 12/04/24
Immunizations
Exam Vital Signs:
O
Temperature: 101°F (38.3°C)
Pulse: 98 bpm
Respirations: 18/min
Blood Pressure: 100/65 mmHg
Oxygen saturation: 98% on room air
General Appearance: Alert, cooperative, in mild distress
due to throat pain.
Head: Normocephalic, atraumatic.
Eyes: PERRLA, EOMI, no conjunctival injection.
Ears: No signs of infection, normal external auditory
canals.
Nose: Mucosa pink, no congestion or discharge.
Mouth/Throat:
Tonsils markedly enlarged, red, and erythematous with
exudate (bilateral).
Soft palate and uvula midline, no signs of peritonsillar
abscess.
No oral ulcers or thrush.
Neck: Tender anterior cervical lymphadenopathy, no
supraclavicular or axillary lymphadenopathy.
Chest/Lungs: Clear to auscultation bilaterally. No
wheezing, rales, or rhonchi.
Cardiovascular: Regular rate and rhythm, no murmurs.
Abdomen: Soft, non-tender, non-distended. No
hepatosplenomegaly.
Musculoskeletal: Full range of motion in all joints. No
swelling or erythema.
Neurologic: Alert and oriented to person, place, and time. Cranial
nerves II-XII intact.
Developmental Weight: 27 kg (50th percentile)
Assessment Height: 130 cm (50th percentile)
(all ages) and -The patient's height and weight are within normal growth
Growth parameters for his age group, suggesting typical physical
Percentile development (Suppiej et al., 2024).
(Pediatric pts. -The patient has age-appropriate language skills. He is able to
only) express himself clearly and is able to follow both simple and
complex instructions (Suppiej et al., 2024).
This study source was downloaded by 100000900934077 from CourseHero.com on 09-08-2025 18:30:02 GMT -05:00
https://www.coursehero.com/file/246170568/SOAP-Note-Week-5docx/
Course:625 L
Date: 12/04/24
Practicum Comprehensive SOAP Note
CC Sore throat for 2 days and fever
S HPI 8-year-old male presents with is mother today, who provides the
history. She reports that he has had a sore throat for the past 2 days
and a fever with a high of 101F.
The patient reports that the sore throat started 2 days ago and has
progressively worsened. He describes the pain as sharp and
constant, especially when swallowing. The pain is localized in the
throat and has not radiated to the ears. He has difficulty
swallowing food but is able to drink fluids, although this is also
somewhat painful.
Associated symptoms include fever (up to 101°F), headache, and
mild fatigue. No cough, nasal congestion, or diarrhea. Denies
abdominal pain or vomiting.
Denies any recent exposure to sick contacts.
Current/PMH No current or previous medical history
Surgical Hx No surgical history
Medications
None
Allergies No known drug allergies
No known seasonal allergies
No known food allergies
Family Hx Non-contributory: no history of autoimmune disorders, chronic
illnesses, or significant infections in immediate family members
Social Hx -Lives with both parents and two siblings in a non-smoking
household.
-Attends school regularly and participates in age-appropriate
activities such as soccer and swimming.
-No exposure to second-hand smoke or environmental toxins.
ROS Constitutional: Fever, fatigue, no weight loss or night sweats.
HEENT: Sore throat, no nasal congestion, no ear pain, no
rhinorrhea, no mouth ulcers.
Cardiovascular: No chest pain, no palpitations.
Respiratory: No cough, no shortness of breath, no wheezing.
GI: No abdominal pain, nausea, vomiting, or diarrhea.
Genitourinary: No dysuria or hematuria.
Musculoskeletal: No joint pain, swelling, or stiffness.
Neurologic: No headaches, dizziness, or loss of consciousness.
This study source was downloaded by 100000900934077 from CourseHero.com on 09-08-2025 18:30:02 GMT -05:00
https://www.coursehero.com/file/246170568/SOAP-Note-Week-5docx/
, Student Name: Brougan Sheets
Course:625 L
Date: 12/04/24
Immunizations
Exam Vital Signs:
O
Temperature: 101°F (38.3°C)
Pulse: 98 bpm
Respirations: 18/min
Blood Pressure: 100/65 mmHg
Oxygen saturation: 98% on room air
General Appearance: Alert, cooperative, in mild distress
due to throat pain.
Head: Normocephalic, atraumatic.
Eyes: PERRLA, EOMI, no conjunctival injection.
Ears: No signs of infection, normal external auditory
canals.
Nose: Mucosa pink, no congestion or discharge.
Mouth/Throat:
Tonsils markedly enlarged, red, and erythematous with
exudate (bilateral).
Soft palate and uvula midline, no signs of peritonsillar
abscess.
No oral ulcers or thrush.
Neck: Tender anterior cervical lymphadenopathy, no
supraclavicular or axillary lymphadenopathy.
Chest/Lungs: Clear to auscultation bilaterally. No
wheezing, rales, or rhonchi.
Cardiovascular: Regular rate and rhythm, no murmurs.
Abdomen: Soft, non-tender, non-distended. No
hepatosplenomegaly.
Musculoskeletal: Full range of motion in all joints. No
swelling or erythema.
Neurologic: Alert and oriented to person, place, and time. Cranial
nerves II-XII intact.
Developmental Weight: 27 kg (50th percentile)
Assessment Height: 130 cm (50th percentile)
(all ages) and -The patient's height and weight are within normal growth
Growth parameters for his age group, suggesting typical physical
Percentile development (Suppiej et al., 2024).
(Pediatric pts. -The patient has age-appropriate language skills. He is able to
only) express himself clearly and is able to follow both simple and
complex instructions (Suppiej et al., 2024).
This study source was downloaded by 100000900934077 from CourseHero.com on 09-08-2025 18:30:02 GMT -05:00
https://www.coursehero.com/file/246170568/SOAP-Note-Week-5docx/
