CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 07/11/24 Time: 0935
J.H.
Ethnicity: Black Age: 23 Sex: M
SUBJECTIVE (must complete this section)
CC: Swollen ear for 2 days
HPI: The patient reports experiencing swelling in his right ear for the past 2 days. The swelling began suddenly and has
progressively worsened. He describes the ear as feeling warm to the touch and mildly painful, especially when lying on
that side or touching the ear. There is no significant discharge from the ear, but he has noticed some redness in the
area. The patient denies any recent trauma or injury to the ear. He also denies experiencing fever, hearing loss,
dizziness, or other systemic symptoms. There is no history of recent upper respiratory infections, swimming, or
inserting any objects into the ear. He has not attempted any treatments or taken any medications for this condition.
Medications:
Previous Medical History: None
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Surgeries: FAMILY HISTORY (must complete this section)
M: Alive- no
hx F: Alive-
Htn
Social History : The patient is a non-smoker and does not use recreational drugs. He occasionally
consumes alcohol. There is no recent travel history. He lives alone and works as a software
developer, spending significant time on the computer daily. He engages in regular physical
activity, including jogging and gym
workouts a few times a week.
REVIEW OF SYSTEMS (must complete this section)
General: Denies fatigue, night sweats and Cardiovascular: Denies syncope, edema,
weakness shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Denies difficulty breathing,
shortness
of breath, labored breathing, tachypnea,
wheezing, retractions, stridor, and hemoptysis.
Eyes: Denies and visual changes, eye Gastrointestinal: Denies abdominal pain,
drainage or eye pain spitting up/vomiting, diarrhea, and changes
in stool.
Ears: Reports right ear pain and swelling Genitourinary/Gynecological: Denies
increased urine output, dysuria. Denies foul
urine and
hematuria
Nose/Mouth/Throat: Denies sore throat or Musculoskeletal: Denies weakness,
nasal restriction of
congestion movement, joint swelling.
Breast: Deferred Neurological: Denies abnormal activity,
abnormal
, movements, and changes in strength.
Heme/Lymph/Endo: Denies swollen glands, Psychiatric: Denies symptoms of
bruising, bleeding, and edema. depression,
anxiety, mood swings, hallucinations,
delusions, or
