CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 07/20/24 Time: 1130
K.L.
Ethnicity: Black Age:4 Sex: F
SUBJECTIVE (must complete this section)
CC: ““Having fever, runny nose, sneezing and cough”
HPI: Mother reports that pt has been experiencing a fever, runny nose, sneezing, and cough for the past 3 days. The
fever has been fluctuating, reaching up to 102°F. The cough is mostly dry and occurs intermittently throughout the
day. No history of sore throat, ear pain, or shortness of breath.
Medications: None
Previous Medical History: None
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major
traumas: None
Hospitalizations/Surgeries:
None
Developmental History: Meeting developmental milestones appropriately. Per parents, gross motor skills are age-
appropriate, demonstrated by the ability to run, jump, climb, and balance well. Fine motor skills are also
developing appropriately, including skills such as drawing, writing, using utensils, and manipulating small objects.
Surgeries: none
FAMILY HISTORY (must complete this section)
M: Alive- Gestational
diabetes F: Alive- no hx
Social History : Pt lives with her parents and a 6-year-old sibling. He attends preschool and has no exposure to tobacco
smoke at home. His family practices good hygiene and ensures that all members have up-to-date immunizations.
REVIEW OF SYSTEMS (must complete this
section)
General: Reports fatigue and fussiness, denies night sweats, Cardiovascular: Denies syncope, edema, shortness of
and weakness breath, and cyanosis.
Skin: Denies rash or swelling Respiratory: Reports congestion, denies difficulty
breathing, shortness of breath, labored breathing, tachypnea,
wheezing, retractions, stridor, and hemoptysis.
Eyes: Denies any visual changes, eye drainage, or eye pain Gastrointestinal: Reports decreased appetite, denies
abdominal pain, spitting up/vomiting, diarrhea, and changes in
stool.
Ears/Nose/Mouth/Throat: Denies ear pain, Genitourinary/Gynecological: Denies
denies sore throat or nasal congestion increased
urine output, dysuria, and increased urinary frequency,
Denies foul urine and hematuria,
Nose/Mouth/Throat: Denies sore throat or Musculoskeletal: Denies weakness, restriction of
nasal movement, joint swelling.
congestion
, Breast: Deferred Neurological: Reports irritability, denies abnormal
activity,
