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Week 5: Focused SOAP Note Sore Throat
Amber LaZelle
School of Nursing: Regis College
NU-650-09-23PCS3 Adv Hlth
Assessment/Nursing Professor Tsahai Hewitt
June 4, 2023
This study source was downloaded by 100000820940918 from CourseHero.com on 10-14-2023 02:56:51 GMT -05:00
https://www.coursehero.com/file/207380443/Focused-SOAP-Note-Sore-Throatdocx/
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Week 5: Focused SOAP Note Sore Throat
06/01/2023, 0900
BL, 21-year-old, male,
student Self-reliable
Chief Complaint
“I have a sore throat, and it is itchy too”
Subjective
History of Present Illness (HPI)
BL is a 21-year-old, Caucasian male who presents to the clinic with complaints of sore
throat the past three days. “My throat has been sore for the last 3 days”. Reports intermittent
cough, rhinorrhea, dysphagia, dysphonia, and feeling achy and tired. He describes his cough as
non-productive, hoarse, but without pain. He rates his sore throat and overall aches using a
numeric pain scale, 5/10 since it began three days ago, coughing lasts for a few minutes about
twice an hour. The cough is intermittent regardless of where he is or what he is doing. Cough
drops seem to soothe some, and Tylenol every helps too, but it is painful to swallow. Positive for
cough, low grade temperature, rhinitis, swelling of throat. Negative for high fever, confusion,
red and swollen tonsils, negative for white patches or streaks of pus, negative for red spots on
the roof of BL’s mouth (Centers for Disease Control and Prevention [CDC], 2022). He denies
congestion.
Allergies: NKA, NKDA, NKFA, and No latex sensitivity
Medications
• Tylenol 500mg tablets by mouth every 6 hours PRN pain (Throat pain)
This study source was downloaded by 100000820940918 from CourseHero.com on 10-14-2023 02:56:51 GMT -05:00
https://www.coursehero.com/file/207380443/Focused-SOAP-Note-Sore-Throatdocx/
Week 5: Focused SOAP Note Sore Throat
Amber LaZelle
School of Nursing: Regis College
NU-650-09-23PCS3 Adv Hlth
Assessment/Nursing Professor Tsahai Hewitt
June 4, 2023
This study source was downloaded by 100000820940918 from CourseHero.com on 10-14-2023 02:56:51 GMT -05:00
https://www.coursehero.com/file/207380443/Focused-SOAP-Note-Sore-Throatdocx/
, 2
Week 5: Focused SOAP Note Sore Throat
06/01/2023, 0900
BL, 21-year-old, male,
student Self-reliable
Chief Complaint
“I have a sore throat, and it is itchy too”
Subjective
History of Present Illness (HPI)
BL is a 21-year-old, Caucasian male who presents to the clinic with complaints of sore
throat the past three days. “My throat has been sore for the last 3 days”. Reports intermittent
cough, rhinorrhea, dysphagia, dysphonia, and feeling achy and tired. He describes his cough as
non-productive, hoarse, but without pain. He rates his sore throat and overall aches using a
numeric pain scale, 5/10 since it began three days ago, coughing lasts for a few minutes about
twice an hour. The cough is intermittent regardless of where he is or what he is doing. Cough
drops seem to soothe some, and Tylenol every helps too, but it is painful to swallow. Positive for
cough, low grade temperature, rhinitis, swelling of throat. Negative for high fever, confusion,
red and swollen tonsils, negative for white patches or streaks of pus, negative for red spots on
the roof of BL’s mouth (Centers for Disease Control and Prevention [CDC], 2022). He denies
congestion.
Allergies: NKA, NKDA, NKFA, and No latex sensitivity
Medications
• Tylenol 500mg tablets by mouth every 6 hours PRN pain (Throat pain)
This study source was downloaded by 100000820940918 from CourseHero.com on 10-14-2023 02:56:51 GMT -05:00
https://www.coursehero.com/file/207380443/Focused-SOAP-Note-Sore-Throatdocx/
