1
HEENT SOAP Note
Name:
United States University
MSN 572: Advanced Physical Assessment Across the Lifespan
Prof. Virginia Butler
June 30, 2025
, 2
ID:
● Client’s Initials: DF Age: 31 DOB: 03/30/1993
● Race/ Ethnicity: Black/ African American Gender: Male
● Arrived: alone.
● Historian: Patient
Subjective
CC: “I woke up with a sore throat yesterday.”
HPI: DF, a 31-year-old African American male, presented to the clinic alone today with
complaints of a sore throat. The patient reports waking up with a sore throat yesterday morning.
He reports 6/10 pain with swallowing, which aggravates the pain. The patient states that the pain
is constant.
Past Medical History:
• Pt denies past medical and surgical history.
Allergies:
● Pt denies allergies to medications, environmental elements, or foods
Medications:
● Pt is not taking any medications currently.
Family History: N/a
Social History:
● Chemical history: Pt denies tobacco use, alcohol use, or other illicit substances
● Living arrangements: Pt lives alone and has not been exposed to sick persons
ROS:
• Constitutional: Pt denies any recent fever, chills, or fatigue
HEENT SOAP Note
Name:
United States University
MSN 572: Advanced Physical Assessment Across the Lifespan
Prof. Virginia Butler
June 30, 2025
, 2
ID:
● Client’s Initials: DF Age: 31 DOB: 03/30/1993
● Race/ Ethnicity: Black/ African American Gender: Male
● Arrived: alone.
● Historian: Patient
Subjective
CC: “I woke up with a sore throat yesterday.”
HPI: DF, a 31-year-old African American male, presented to the clinic alone today with
complaints of a sore throat. The patient reports waking up with a sore throat yesterday morning.
He reports 6/10 pain with swallowing, which aggravates the pain. The patient states that the pain
is constant.
Past Medical History:
• Pt denies past medical and surgical history.
Allergies:
● Pt denies allergies to medications, environmental elements, or foods
Medications:
● Pt is not taking any medications currently.
Family History: N/a
Social History:
● Chemical history: Pt denies tobacco use, alcohol use, or other illicit substances
● Living arrangements: Pt lives alone and has not been exposed to sick persons
ROS:
• Constitutional: Pt denies any recent fever, chills, or fatigue
