SOAP Note 3 Form CP1

SOAP Note 3 Form CP1
S/ Identifying Information: (initials, age, gender, reliability) Family Hx:
Pat Jones Is an 11 year old male accompanied by mom. She is the primary historian. Maternal Mother
HTN DM and
Paternal father
heart disease and
triple bypass
surgery
Personal/Social
Chief Concern/RFE: Lives with
mother, father,
and younger
sister who is in 1st
grade
“He has been having throat pain and fever for 3 days.”
Hx Present Illness: (write in paragraph format)
HPI: Patient has had throat pain and fever for 3 days. Mother states a few kids in his class were sick but is unsure of
what they have. Patient’s throat pain is constant and worsening when eating. She has been giving him ibuprofen but
there has not been any relief to his symptoms. She states that he is usually in good health.
CURRENT HEALTH
Medications: children’s ibuprofen; mother follows instructions on back
Allergies:pcn – hives
Last PE & Screenings: none
Immunization Status: not vaccinated for covid-19; is up to date on all other vaccines
LMP & Birth Control (if applicable) n/a
PMH
Illnesses & Trauma: bilateral ear tubes at 2 years old
Hospitalizations/Surgeries: none
OB Hx/Sexual Hx: n/a
Emotional/Psy Hx: n/a
REVIEW OF SYSTEMS
General: fever, acutely ill, able to get sleep at night
Nutrition: adequate PO intake