1
SOAP Note
SUBJECTIVE:
Chief complaint: 12 year old female who presents to clinic for wellness exam with complaints
of sore throat and fever.
History of Present Illness (HPI): Addison is a 12-year-old Caucasian female adolescent who
presents to clinic for routine wellness exam. Addison states she has been healthy with no
concerns until about 3 days ago when her throat became scratchy. Yesterday evening she
developed a fever of 101 and the scratchy throat turned to burning and painful when
swallowing. Pain is described as constant, burning pain that is a 5/10. Took Ibuprofen (1 tab,
200mg) last night and this morning to help with pain. Drinking fluids (water and gatorade) helps
relieve the scratch but not the pain. Addison denies using salt water gargling or throat lozenges
for pain relief. Denies headaches, runny nose, postnasal drip or cough.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Generally no complaints. Normal activity level, sleeping well (8-10) hours a
night. One of smallest kids in class but has recently gained 5 pounds over the past few
months.
EYES: patients states, “some things in class are blurry when not wearing glasses or contacts”.
Denies itchy, watery, or dry eyes. No redness, no double vision. Last eye exam was in June
2025, when she got her contacts from her eye doctor.
EARS, NOSE, MOUTH/THROAT: No otorrhea, no earaches, no congestion, no runny nose, no
snoring. No postnasal drip. No mouth sores, gum or jaw problems. Pain with swallowing that
started last night (9/28 PM). Pain 5/10. Denies neck pain.
TEETH: No cavities. Brushes teeth 2-5 times a day, sees dentist and orthodontist regularly. Has
Invisalign. If cannot brush teeth, chews gum before replacing Invisalign trays. No cavities to
date.
CARDIOVASCULAR: No history of heart murmur, no cyanosis. No chest pain with activity. No
palpitations.
RESPIRATORY: No cough, shortness of breath, or increased work of breathing,
GI: patient was diagnosed with celiac’s disease at age of 7. Avoids gluten. Has what patient
states are normal stools about every day. Denies abdominal pain, nausea, emesis or diarrhea.
Gained 5 lbs. over last few months. Only has bloating when accidentally ingesting gluten.
GU: Urinates without any pain, difficulty or hesitancy. No hematuria.
GYNECOLOGICAL: Has not started menstruation. No pelvic pain. Mother started menstruation
at age 14.
NEUROLOGICAL: Addison has no problems concentrating in class or remembering things.
Denies headaches, weakness or dizziness.
ENDOCRINE: Diagnosed with hypothyroidism at birth. Takes levothyroxine daily as soon as she
wakes up. Mother states her most recent labs for her TSH and T4 were normal. No med
adjustments have been needed. Next endocrine appointment is December 2025.
HEMATOLOGY: No ecchymosis, petechiae or bleeding.
MUSCULOSKELETAL: Denies muscle pain, muscle weakness.
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:16:06 GMT -06:00
https://www.coursehero.com/file/253766536/SOAP-NOTE-sick-child-strep-throatdocx/
, 2
DERMATOLOGY: patient describes skin as occasionally itchy and dry. No recent rashes.
Past Medical History: Addison was born full term. Uncomplicated delivery. 6 lbs 8 oz. 19.5
inches long. Diagnosed with hypothyroidism on newborn screen. Gets lab testing every 4
months now. Allergy testing in 2020-positive for pistachios and gluten. Celiac diagnosis in 2020
as well. Mother denies any accidents and injuries. No hospitalizations.
Past Surgical History: Upper GI biopsy for celiacs disease – 2020
Allergies: Gluten- bloating, with vomiting and/or diarrhea. Pistachios- tingly tongue, red
welts/hives on skin. Allergy testing was positive for pistachios. Used to avoid all tree nuts but
has passed all food challenges with walnuts, almonds and cashews. Next allergist appointment
is December 2025.
Immunizations: Mother reports patient up to date on all immunizations. Will get flu shot in the
fall as well. Mother states patient has received dose one of HPV vaccine.
Diet: Addison eats 3 meals a day with 2-3 snacks as well. Avoids gluten, and pistachios. Drinks 2
Owala water bottles (24oz) a day during school, as well as 1 mini soda/gatorade with lunch.
Addison states breakfast is on the go, while walking to school after her thyroid meds have been
in for at least 30 minutes. Breakfast- banana, protein smoothie and gf breakfast bar.
Lunch- Usually takes a turkey sandwich or PBJ, a cheese stick and doritos. Dinner- Mom
cooks. Typical meals of tacos, pizza, spaghetti, etc. Dad grills on the weekends.
Snacks: fruit, veggies and hummus, cheese and lunch meat, chips, yogurt and
granola, ice cream after dinner, or gluten free cookies.
Medications: Levothyroxine 0.25mg PO daily, 30 minutes before breakfast
Epi Pen Jr- Epi Pen Jr- 0.15mg SC/IM PRN for anaphylaxis allergic
reaction
Ibuprofen 200mg PO every 4-6 hours for pain relief or fever
Family History: Paternal Grandfather - History of prostate cancer and heart attack. Paternal
Grandmother - Healthy with no known medical problems Maternal Grandfather - Healthy with
no known medical problems Maternal Grandmother- History of celiacs disease Mother- History
of hypothyroidism Father - Healthy with no known medical problems besides allergy to walnuts.
Siblings- Healthy with no known medical problems There is no family history of diabetes,
seizures, cancer, hypertension or sickle cell on the maternal side. The paternal side has history
of cancer and heart disease.
Social History: Lives at home with mom, dad, sister and brother. Both parents work, mom is a
teacher and dad works in accounting. Their residence contains no pets, as of the past year. No
one in the home smokes. No firearms in the home. Addison is in advanced classes in 7th grade
maintaining all A’s. She participates in competition dance and the school dance team. Addison
denies drinking alcohol or drug use. She is not sexually active and has not started menses.
Patient reports “her favorite part of school is lunch time so she can hang with her friends”. She
also enjoys walking home with friends at the end of the day. She practices safe habits such as
wearing a helmet when riding a boke or rollerblading and wearing sunscreen when at the pool.
She no longer sits in a booster seat in the car and always wears a seatbelt. She denies any
depression, suicidal ideations or mental health issues. She feels safe and denies being harmed
in any way.
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:16:06 GMT -06:00
https://www.coursehero.com/file/253766536/SOAP-NOTE-sick-child-strep-throatdocx/
SOAP Note
SUBJECTIVE:
Chief complaint: 12 year old female who presents to clinic for wellness exam with complaints
of sore throat and fever.
History of Present Illness (HPI): Addison is a 12-year-old Caucasian female adolescent who
presents to clinic for routine wellness exam. Addison states she has been healthy with no
concerns until about 3 days ago when her throat became scratchy. Yesterday evening she
developed a fever of 101 and the scratchy throat turned to burning and painful when
swallowing. Pain is described as constant, burning pain that is a 5/10. Took Ibuprofen (1 tab,
200mg) last night and this morning to help with pain. Drinking fluids (water and gatorade) helps
relieve the scratch but not the pain. Addison denies using salt water gargling or throat lozenges
for pain relief. Denies headaches, runny nose, postnasal drip or cough.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Generally no complaints. Normal activity level, sleeping well (8-10) hours a
night. One of smallest kids in class but has recently gained 5 pounds over the past few
months.
EYES: patients states, “some things in class are blurry when not wearing glasses or contacts”.
Denies itchy, watery, or dry eyes. No redness, no double vision. Last eye exam was in June
2025, when she got her contacts from her eye doctor.
EARS, NOSE, MOUTH/THROAT: No otorrhea, no earaches, no congestion, no runny nose, no
snoring. No postnasal drip. No mouth sores, gum or jaw problems. Pain with swallowing that
started last night (9/28 PM). Pain 5/10. Denies neck pain.
TEETH: No cavities. Brushes teeth 2-5 times a day, sees dentist and orthodontist regularly. Has
Invisalign. If cannot brush teeth, chews gum before replacing Invisalign trays. No cavities to
date.
CARDIOVASCULAR: No history of heart murmur, no cyanosis. No chest pain with activity. No
palpitations.
RESPIRATORY: No cough, shortness of breath, or increased work of breathing,
GI: patient was diagnosed with celiac’s disease at age of 7. Avoids gluten. Has what patient
states are normal stools about every day. Denies abdominal pain, nausea, emesis or diarrhea.
Gained 5 lbs. over last few months. Only has bloating when accidentally ingesting gluten.
GU: Urinates without any pain, difficulty or hesitancy. No hematuria.
GYNECOLOGICAL: Has not started menstruation. No pelvic pain. Mother started menstruation
at age 14.
NEUROLOGICAL: Addison has no problems concentrating in class or remembering things.
Denies headaches, weakness or dizziness.
ENDOCRINE: Diagnosed with hypothyroidism at birth. Takes levothyroxine daily as soon as she
wakes up. Mother states her most recent labs for her TSH and T4 were normal. No med
adjustments have been needed. Next endocrine appointment is December 2025.
HEMATOLOGY: No ecchymosis, petechiae or bleeding.
MUSCULOSKELETAL: Denies muscle pain, muscle weakness.
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:16:06 GMT -06:00
https://www.coursehero.com/file/253766536/SOAP-NOTE-sick-child-strep-throatdocx/
, 2
DERMATOLOGY: patient describes skin as occasionally itchy and dry. No recent rashes.
Past Medical History: Addison was born full term. Uncomplicated delivery. 6 lbs 8 oz. 19.5
inches long. Diagnosed with hypothyroidism on newborn screen. Gets lab testing every 4
months now. Allergy testing in 2020-positive for pistachios and gluten. Celiac diagnosis in 2020
as well. Mother denies any accidents and injuries. No hospitalizations.
Past Surgical History: Upper GI biopsy for celiacs disease – 2020
Allergies: Gluten- bloating, with vomiting and/or diarrhea. Pistachios- tingly tongue, red
welts/hives on skin. Allergy testing was positive for pistachios. Used to avoid all tree nuts but
has passed all food challenges with walnuts, almonds and cashews. Next allergist appointment
is December 2025.
Immunizations: Mother reports patient up to date on all immunizations. Will get flu shot in the
fall as well. Mother states patient has received dose one of HPV vaccine.
Diet: Addison eats 3 meals a day with 2-3 snacks as well. Avoids gluten, and pistachios. Drinks 2
Owala water bottles (24oz) a day during school, as well as 1 mini soda/gatorade with lunch.
Addison states breakfast is on the go, while walking to school after her thyroid meds have been
in for at least 30 minutes. Breakfast- banana, protein smoothie and gf breakfast bar.
Lunch- Usually takes a turkey sandwich or PBJ, a cheese stick and doritos. Dinner- Mom
cooks. Typical meals of tacos, pizza, spaghetti, etc. Dad grills on the weekends.
Snacks: fruit, veggies and hummus, cheese and lunch meat, chips, yogurt and
granola, ice cream after dinner, or gluten free cookies.
Medications: Levothyroxine 0.25mg PO daily, 30 minutes before breakfast
Epi Pen Jr- Epi Pen Jr- 0.15mg SC/IM PRN for anaphylaxis allergic
reaction
Ibuprofen 200mg PO every 4-6 hours for pain relief or fever
Family History: Paternal Grandfather - History of prostate cancer and heart attack. Paternal
Grandmother - Healthy with no known medical problems Maternal Grandfather - Healthy with
no known medical problems Maternal Grandmother- History of celiacs disease Mother- History
of hypothyroidism Father - Healthy with no known medical problems besides allergy to walnuts.
Siblings- Healthy with no known medical problems There is no family history of diabetes,
seizures, cancer, hypertension or sickle cell on the maternal side. The paternal side has history
of cancer and heart disease.
Social History: Lives at home with mom, dad, sister and brother. Both parents work, mom is a
teacher and dad works in accounting. Their residence contains no pets, as of the past year. No
one in the home smokes. No firearms in the home. Addison is in advanced classes in 7th grade
maintaining all A’s. She participates in competition dance and the school dance team. Addison
denies drinking alcohol or drug use. She is not sexually active and has not started menses.
Patient reports “her favorite part of school is lunch time so she can hang with her friends”. She
also enjoys walking home with friends at the end of the day. She practices safe habits such as
wearing a helmet when riding a boke or rollerblading and wearing sunscreen when at the pool.
She no longer sits in a booster seat in the car and always wears a seatbelt. She denies any
depression, suicidal ideations or mental health issues. She feels safe and denies being harmed
in any way.
This study source was downloaded by 100000900703063 from CourseHero.com on 02-09-2026 16:16:06 GMT -06:00
https://www.coursehero.com/file/253766536/SOAP-NOTE-sick-child-strep-throatdocx/
