MSN 572: Advanced Physical Assessment Across the Lifespan: HEENT SOAP Note | Answered 2025.

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HEENT SOAP Note



Name:

United States University

MSN 572: Advanced Physical Assessment Across the Lifespan

Prof. Virginia Butler

June 30, 2025

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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