NURS 5337 SOAP Note 3 for FNP CP1 complete solutions-2026 update University of Texas, Arlington

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 mother, father, and younger sister who is in 1st grade “He has been having throat pain and fever for 3 days.” Hx Present Illness: (write in paragraph format) 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 lbs / 37.5kg BMI: 16.2 (healthy) P: 76/min R: 20/min BP: 102/54 HT: 57 inches WT: 75 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 I. PLAN: Diagnostics: GAS rapid antigen detection (throat swab), Rapid antigen covid test Positive GAS antigen test noted in office Lymph- no palpable cervical nodes MSK - Posture erect with smooth, even, steady gait. No tremors or tics noted. ROM with active and passive ROM noted bilat, shoulders, elbows wrists, hands and fingers as well as hips, knees, ankles, feet and toes. Neuro steady gait and positive hearing, able to follow commands. Medical Dx: J02.0 Streptococcal pharyngitis J02.8 Acute pharyngitis due to other specified organisms J01 Acute sinusitis A49.2 Hemophilus influenzae infection U07.1 COVID -19 Rule Outs (only if applicable): No lymphadenopathy-r/o pharyngitis No sinus pressure or headaches- r/o sinusitis No cough or changes in appetite- r/o COVID No SOB- r/o flu Health Profile: child in school at risk age/gender/racial risks: risk for COVID-19 infection- unvaccinated school aged child Pertinent Positives: main diagnosis Streptococcal pharyngitis- Fever, sore throat, tonsillar exudate lymphadenopathy, abdominal pain, no cough, age 3-14 years Winter season personal/family: sister and parents in contact with possible sick contacts screening needs: Nasal swab- Rapid antigen for COVID- 19 Pertinent Negatives: no nasal congestion or cervical adenopathy counseling needs: Vaccines Immunization/chemo needs: