Episodic/Focused SOAP note
Name
Walden University
NURS 6512 Advanced Health Assessment and Diagnostic Reasoning
2022
This week’s case study
Lily is a 20-year-old student at the local community college.
Patient Information: 20 -year old who is attending a community college.
S.
Chief Complain: sore throat, decreased appetite, headache, painful swallowing.
History of Patient Illness (HPI): She also experiences diminished appetite, headache and
swallowing discomfort. She tried her throat lozenge medicine, but when the drug is worn out, her
sore throat returns. She has a rusty voice, but it doesn't sound overwhelmed.
Current Medications: None
Allergies: Exhibits none of known allergies
Social History: She is a college student. Drinks alcohol occasionally but denies smoking
cigarettes.
Past Medical History (PMH): Presents no past MH.
Family History: Mother 60 -years-old has hypertension and hypothyroidism. Father 62- years
old has emphysema and coronary heart disease.
ROS:
GENERAL: 6Pt has not lost any weight, though she is fatigued
HEENT: 6Eyes: no loss of vision, sclera is very clear
Ears, Nose, Throat: 6No loss of hearing, the patient exhibits a runny nose and voice hoarseness
SKIN: 6No rash.
