The patient is an 11-year-old Native American girl who resides with her biological father, his girlfriend, two younger sisters, and a newborn, half-brother in a small apartment located on a reservation in Southeast South Dakota. The patient is in 5th grade and attends the public school. The patient’s presenting problem is her behavior, which is […]

A 45-year-old patient presents to the primary care clinic with a sudden onset of unilateral facial weakness. The patient describes experiencing drooling, loss of taste on the affected side, and ear pain. There are no reports of fever, neck stiffness, or other systemic symptoms. Physical examination reveals flaccid paralysis of the facial muscles on one […]

A 24-year-old cisgender male (pronouns: he, him, his) comes to the clinic with concerns about an STI. He states he had unprotected sex with a new male partner several weeks ago. His partner later told him he had been treated for syphilis “a couple of months ago”. He has no symptoms and no significant physical […]

SOAP note example A 21 year old college junior basketball player states that during practice she felt a sharp pain in her chest. She experiences shortness of breath, chest tightness, wheezing, a rough cough. Her current pain level is 2 out of 10 at rest and 8 out of 10 pain when practicing or conditioning. […]