CC: “I am here for my annual, but also I’ve been having a burning feeling in my throat that sometimes makes my
throat sore."
HPI: The patient reports coming in for her annual but has experiencing a burning sensation in her throat, primarily
occurring after meals and when lying down. This sen...
CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 08/22/24 Time: 1115
S.K.
Ethnicity: White Age: 26 Sex: F
SUBJECTIVE (must complete this section)
CC: “I am here for my annual, but also I’ve been having a burning feeling in my throat that sometimes makes my
throat sore."
HPI: The patient reports coming in for her annual but has experiencing a burning sensation in her throat, primarily
occurring after meals and when lying down. This sensation has been present intermittently for the past two months.
She also mentions occasional sore throat, particularly in the morning. She denies any difficulty swallowing, hoarseness,
chest pain, shortness of breath or significant weight changes. She has not tried any medications for this condition.
Previous Medical History: Denies
Medications: None
Allergies: Sulfa- rash
Medication Intolerances: Sulfa
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, occasional alcohol use, no drug use, works as an administrative
assistant, exercises regularly, and follows a balanced diet.
REVIEW OF SYSTEMS (must complete this
section)
General: Denies fatigue, night sweats and Cardiovascular: Denies, palpitations, chest
weakness pain,
shortness of breath, and cyanosis.
Skin: Denies rash Respiratory: Denies cough or shortness of
breath
Eyes: Denies and visual changes, eye Gastrointestinal: Reports a burning sensation in
drainage or eye pain the throat after meals, no abdominal pain, nausea,
vomiting,
or changes in bowel habits.
Ears: Denies ear pain and swelling Genitourinary/Gynecological: Denies
increased
urine output, dysuria. Denies foul urine and
hematuria
Nose/Mouth/Throat: Occasional sore Musculoskeletal: Denies pain or muscle
throat, no nasal congestion weakness
Breast: Deferred Neurological: Denies numbness, tingling or
weakness in the legs
Heme/Lymph/Endo: Denies swollen Psychiatric: Denies symptoms of
glands, bruising, bleeding, and edema. depression, anxiety, mood swings,
, hallucinations, delusions, or
behavioral disturbances.
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