Problem-focused soap note prompt Please be sure to write the SOAP note as though it was a real patient and include the relevant expected information/findings such as vitals and the answers to the subjective data questions and the expected findings of the objective data. Please add any relevant information about the patient that will help.
PATIENT: 13 y/o male brought into the clinic by his mom with Chief Complaints of nasal congestion, non-productive cough worse at night, headache and sore throat for the past 10 days. School is starting in 3 days and Mom wanted to ensure that he was OK to return. States he first noticed a tickle in his throat 10 days ago and that caused him to cough. That night he began having chills and when his mom checked his temp it was 102 so she gave him Tylenol which helped the fever and chills. Tylenol for fever was given for 3 days but the fever resolved after that but the remainder of the symptoms persist. He has tried OTC Theraflu with minimal relief but takes Nyquil at night which is helping him sleep. He has a decreased appetite but has been drinking smoothies to keep up his nutrition. Denies trouble hearing No changes in bowel or bladder. No one else in family is ill. Has seasonal allergies Hx: Strep throat 2 years ago and has had headaches a few times a year since age 7 usually resolve with Tylenol. otherwise denies any medical hx
