Free Patient Soap Note

Prepared by: [Your Name]

I. Subjective (S)

A. Chief Complaint

The patient reports experiencing a sore throat for the past 3 days, accompanied by mild fever and difficulty swallowing.

B. History of Present Illness

The patient describes the sore throat as constant, with a sharp pain that worsens when swallowing. They also report feeling fatigued and having a low-grade fever of around 100°F. No cough or runny nose was noted. Denies recent contact with sick individuals.

C. Past Medical History

No significant past medical history. The patient is generally healthy with no chronic conditions.

D. Medications

The patient is not taking any regular medications.

E. Allergies

No known drug allergies.

II. Objective (O)

A. Vital Sign

B. Physical Examination

C. Laboratory Results

Rapid strep test negative. No other lab work was performed.

III. Assessment (A)

• Likely viral pharyngitis, given the absence of significant fever, rash, or pus on the tonsils. The negative rapid strep test supports this diagnosis.

• Differential diagnosis includes bacterial pharyngitis, but this is less likely based on the clinical presentation and rapid strep result.

IV. Plan (P):

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