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Week 5 Focused SOAP Note Sore Throat complete

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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 Week 5: Focused SOAP Note Sore Throat 06/01/2023, 0900 BL, 21-year-old, male, student Self-reliable Chief C...

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  • October 14, 2023
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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/

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