SOAP Medical Note: Template with an Example Patient Case

• S: Subjective
• O: Objective
• A: Assessment
• P: Plan

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Patient’s Identification Information:

Patient Name:
Age/Gender:
Date of Birth (DOB):
(Optional) Medical Record Number (MRN):

Subjective (S):

Chief Complaint (CC): Sore throat.

History of Presenting Illness (HPI):

Jane Doe is an 18-year-old Caucasian Female who presents with a sore throat for the past 2 days;
she rates the pain as an 8/10, and describes it as aching and constant. She states, “I woke up a
couple of days ago, and all of a sudden it really hurt to swallow.” She adds that swallowing
saliva, in addition to eating food and drinking fluids, exacerbates the pain. She reports taking
over-the-counter Halls© cough drops as-needed, and has been taking 400 mg of Advil every 8
hours, for mild, temporary relief of her pain and intermittent fever. Drinking hot tea two to three
times per day also helps, as it temporarily relieves the severity of the pain. Associated symptoms
include: Fever (TMax 101.0 F, taken using an at-home thermometer), painful, swollen lymph
nodes in her upper neck, and fatigue. Patient is noted to be a freshman college student; she states
her roommate has had similar symptoms for the past 4 days. She says she has missed the last
two days of classes, “Because it’s too tiring to even get up.”

Review of Systems (ROS):

Constitutional: +Fever, + fatigue. Denies chills, unexpected weight loss.

HEENT: +Sore throat, +lymphadenopathy. Denies stiff neck, ear pain.
Respiratory: Denies cough, shortness of breath.
Cardiovascular: Denies chest pain, palpitations.
Gastrointestinal: Denies abdominal pain, nausea, vomiting.
Musculoskeletal: Denies myalgias, joint swelling.
Neurological: Denies headache, numbness, tingling.

Medical History:
• Past Medical History: Migraine headache
• Past Psychiatric History: Denies

MTS; 03/2022
 • Past Surgical History: Appendectomy (2010; no complications)
• Hospital admissions: Denies
• Medications:
o Sumatriptan 50 mg PO PRN
o Over-the counter Claritin 10 mg PO PRN
o Over-the-counter Advil 400 mg PO q8 hours PRN
• Allergies:
o Drugs: None
o Seasonal: Dust & dander
o Food: None
• Family History:
o Mother: Living; +PMHx of Hypertension
o Father: Living; +PMHx of Right Knee Arthritis
o Paternal Grandfather: Deceased; +Pancreatic cancer

Social History:
• Last Menstrual Period (LMP): 2 weeks ago; patient reports a regular cycle occurring
every 28-30 days. She denies using birth control pills.
• Follow-up with a women’s health provider (Gynecologist, midwife, NP, PA, etc.)?: Yes;
Dr. Joanne Smith (100 Main Street, City, New Jersey, 00000)
• Sexual History: +Sexually active with her boyfriend for the past 1 year (Monogamous);
uses barrier protection during vaginal intercourse. Denies history of sexually transmitted
infection
• Smoking History: Denies cigarette smoking. Denies exposure to second-hand smoke.
• Recreational Drug Use History: Denies
• Alcohol Consumption History: Denies
• Occupation: College student
• Physical Activity/Exercise: Walks for 30 minutes daily on treadmill, 5-6 days each week.
• Stressors: Upcoming semester final examinations
• Vaccination History:
o Influenza Vaccination: Received on 09/01/2021. Reports receiving the flu shot at
the beginning of each academic year.
o Covid-19 Vaccination:
§ 1st Dose: 02/01/2021
§ 2nd Dose: 03/01/2021
§ Booster Shot: 12/01/2021

Objective (O):

Physical Examination:

Vital Signs (VS): Height 60”; Weight: 130 lbs; Temperature 100.0 F; BP 122/74 mm Hg; HR 80
BPM; RR 14 breaths per minute; SpO2 99% on room air
Constitutional: +Mild flushing of bilateral cheeks. No acute distress. Non-toxic-appearing.

MTS; 03/2022
HEENT: Normocephalic; atraumatic. +Moderately erythematous pharynx, with 2+ tonsillar
enlargement with exudate bilaterally. +Tender lymphadenopathy in the posterior cervical
chain.
Respiratory: Lung sounds are clear in superior and posterior lung fields. Bilateral and
symmetrical chest rise noted
Cardiovascular: S1 and S2 are audible; there are no murmurs, rubs, or gallops auscultated
Abdomen: Soft, non-tender in all four quadrants. Bowel sounds are normal.
Musculoskeletal: No lower extremity edema noted.

Assessment (A):

1. Exudative pharyngitis: Rule out Mononucleosis versus Streptococcus pharyngitis versus

viral etiology
2. Upper respiratory infection

Plan (P):

1. Monospot test and Rapid Strep test ordered to be performed in-house today; pending
results.
a. Should Rapid Strep test be Positive: Prescribe Penicillin V 500 mg PO BID for 10
days
b. Should Monospot test be Positive: Recommend conservative measures, including
drinking plenty of fluids, resting from school and getting enough sleep, and using
over-the-counter Tylenol or Ibuprofen to manage pain and/or fever. Advise the
patient to avoid strenuous activity or sports, as there may be undetected
splenomegaly that could lead to rupture
c. Should the Monospot test or Rapid Strep test result as Negative: Patient most
likely has a viral pharyngitis. Recommend conservative measures, including
drinking plenty of fluids, resting from school and getting enough sleep, and using
over-the-counter Tylenol or Ibuprofen to manage pain and/or fever.
2. Recommend a follow-up visit in 1 week to monitor progress of patient’s symptoms, and
to assess for improvement.

MTS; 03/2022