HEENT Nursing SOAP Note Example

Below is a nursing SOAP note for a HEENT (Head, Eyes, Ears, Nose, Throat) examination based on a case study, incorporating all applicable components and subcomponents, and utilizing the OLDCART acronym in the History of Present Illness (HPI) section:

Review: Other Nursing SOAP Notes Examples

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Subjective:

1. Chief Complaint: Patient reports a sore throat and difficulty swallowing.
2. HPI (History of Present Illness):
   • Onset: The patient states that the symptoms started two days ago.
   • Location: The patient reports experiencing the sore throat primarily in the back of their throat.
   • Duration: The patient mentions that the symptoms have been constant since their onset.
   • Character: The patient describes the sore throat as a sharp, burning pain that worsens with swallowing. They also report feeling a dry sensation in the throat.
   • Aggravating Factors: The patient reports that the pain intensifies with swallowing, particularly when consuming solid foods.
   • Relieving Factors: The patient states that drinking warm fluids and gargling with saltwater provide temporary relief.
   • Treatment/Interventions Tried: The patient has been taking over-the-counter pain relievers for symptom relief.
3. Past Medical History: Document any relevant past medical conditions or surgeries that may have an impact on the current symptoms, such as a history of recurrent tonsillitis or chronic pharyngitis.
4. Allergies: Inquire about any known allergies the patient has, including medication allergies or allergies to specific substances, such as latex.
5. Current Medications: Record a comprehensive list of the patient’s current medications, including prescription medications, over-the-counter medications, and herbal supplements.
6. Social History: Gather information about the patient’s lifestyle, occupation, and any recent exposures or activities that may be relevant to their current symptoms. Inquire about smoking history and alcohol consumption, as these may contribute to throat-related symptoms.
7. Travel History: Determine if the patient has traveled recently, especially to areas with a higher prevalence of infectious diseases. This information can help identify potential exposures or infections.
8. Immunization History: Assess the patient’s immunization status, specifically in relation to vaccinations for conditions such as influenza or streptococcal infections.
9. Family Medical History: Inquire about any relevant family history of recurrent sore throats, tonsillitis, or other conditions that may be related to the current symptoms.
10. Psychosocial History: Assess the patient’s psychosocial well-being and any psychosocial factors that may be contributing to their symptoms, such as stress, anxiety, or recent life events.

Objective:

1. Vital Signs: Blood pressure: 120/80 mmHg, Heart rate: 80 bpm, Respiratory rate: 16 breaths per minute, Temperature: 37.1°C.
2. General Appearance: The patient appears well-nourished and in no acute distress.
3. Head: Normocephalic, no signs of trauma or abnormalities.
4. Eyes: Pupils equal and reactive to light (PEARL), no redness, discharge, or swelling observed.
5. Ears: No external abnormalities, no tenderness or swelling noted.
6. Nose: No external abnormalities, no nasal discharge or tenderness observed.
7. Throat: Erythema and swelling of the tonsils, presence of white patches on the tonsils, uvula midline.

Assessment:

1. Medical Diagnosis: Pharyngitis.
2. Problem Identification: Patient reports sore throat, pain with swallowing, and white patches on the tonsils.
3. Relevant Findings and Abnormalities: Erythema and swelling of the tonsils, white patches on the tonsils.
4. Client Education Needs: Patient requires education on symptom management, including pain relief strategies and self-care measures for pharyngitis.

Plan:

1. Medical Interventions:
   • Recommend over-the-counter analgesics for pain relief.
   • Advise the patient to maintain adequate hydration and drink warm fluids to soothe the throat.
   • Instruct the patient to gargle with warm saltwater several times a day to reduce inflammation.
2. Patient Education:
   • Educate the patient about the self-limiting nature of viral pharyngitis and the importance of rest and adequate fluid intake.
   • Provide information on proper hand hygiene to prevent the spread of infection.
   • Explain the importance of completing the full course of prescribed medications if the infection is determined to be bacterial.
3. Referrals or Consultations:
   • Consult with a healthcare provider for further evaluation if symptoms worsen or persist beyond a week.
4. Safety Measures:
   • Advise the patient to avoid smoking, irritants, and exposure to secondhand smoke.
5. Evaluation:
   • Schedule a follow-up appointment in one week to reassess symptoms and evaluate the effectiveness of interventions.
   • Monitor for any complications or worsening of symptoms.

• This example demonstrates a HEENT SOAP note based on a case study, incorporating all applicable components and subcomponents.
• The subjective section captures the patient’s chief complaint and provides a detailed HPI using the OLDCART acronym.
• The objective section includes vital signs and a thorough examination of the head, eyes, ears, nose, and throat.
• The assessment section includes the medical diagnosis and relevant findings. The plan outlines the medical interventions, patient education, referrals or consultations, safety measures, and a plan for evaluation.