Comprehensive SOAP Exemplar
Patient Initials: WM Age: 9 Gender: F
SUBJECTIVE DATA:
Chief Complaint (CC): “Were here for her 9-year physical and flu shot.”
History of Present Illness (HPI): WM is a 9-year-old Caucasia
...
Comprehensive SOAP Exemplar
Patient Initials: WM Age: 9 Gender: F
SUBJECTIVE DATA:
Chief Complaint (CC): “Were here for her 9-year physical and flu shot.”
History of Present Illness (HPI): WM is a 9-year-old Caucasian female here today with her
mother for her annual physical and flu vaccination. Mom states that MS has been coughing,
runny nose of clear drainage, and sneezing on and off for the last few months. She states that
symptoms worsen when she visits her sister, who lives on a farm, but also occur in the spring and
fall also. She has tried Vicks on her feet and chest, which provides minimal comfort. Mom is
concerned why these symptoms come and go. Denies fevers, chills, and appetite is good. She has
no issues or concerns with MS’s growth or develop
Reflection: I first evaluated this patient independently, obtained a history, then performed an
assessment. Then the assessment was also performed with my preceptor. After the assessment
was performed, my first thought was a sinus infection, but with reservation. As I progressed
along, I realized that these issues are most likely allergic rhinitis. It was helpful that mother was
a good historian and was able point out when the symptoms occur, such as they worsened when
WM was on a farm and in the spring and fall. That leads me to believe that the animals on the
farm and pollen is the trigger. My preceptor agreed with my assessment findings and diagnosis.
As my clinic progresses, I realize the importance of looking at the whole picture, such as the
patient’s history, and not to just focus on the symptoms.
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