Erie Community College
Title III
English Composition Assignment
Interdisciplinary Course Materials
Biology
SOAP note patient interview – Step 2
Practitioner: Hi Justin. My name is Kate Walsh. I am the family nurse practitioner who is seeing you today. Did you come alone, or is someone else with you?
Patient: My Mom dropped me off, she had to go back to work. I’m supposed to call my Dad at work when I’m through, and he will come pick me up. Here’s their permission for me to be treated. (Hands a note to the FNP.)
Practitioner: Okay. (Pause) I see that you’ve had a sore throat and sore ears for about 2 days. Also some purulent nasal discharge. (Seeing a puzzled look on Justin’s face, she thinks about it and rephrases the last statement.) You know, thick, colored, yucky stuff coming out of your nose.
Patient: Oh, yeah. It’s really green! Sometimes it seems like it’ll never stop when I blow my nose!
Practitioner: Yecch – gross. Have you had a temperature, do you think?
Patient: Dunno.
Practitioner: Dunno as you aren’t sure, or dunno – probably not.
Patient: Not sure – maybe. My head has been feeling funny the last couple of days – I feel like I’m under water. Sounds are muffled. Sometimes I’m sweaty.
Practitioner: Oh, I’m sorry. Is there anything else that you felt?
Patient: It’s hard to sleep because it’s hard to breathe. When I wake up in the morning my throat really hurts!
Practitioner: Were your eyes every goopy – at least, or especially, in the morning?
Patient: No, not really.
Practitioner: Okay. Did your Mom or Dad give you anything to make you feel better, or did you take anything on your own. If you did, did it help?
Patient: Mom gave me some Tylenol Cold night before last. It might have helped a little. Coming to see you was my idea. This is really going around at school, and I don’t want to be sick for the weekend!
Practitioner: Something important this weekend?
Patient: There’s a skateboard competition – and I want to be in it.
Practitioner: Got it. Okay then, you’ve told me you have had a sore throat, congestion, lots of green mucous from your nose, and your ears hurt. Do you have a cough?
Patient: In the morning, but that’s all. I’ve coughed up some of the green stuff.
Practitioner: Have you ever heard yourself wheeze when you are breathing?
Patient: No
Practitioner: I can see that you have allergies. There are dark shadows under your eyes, and see this line across your nose. It’s called a sniff mark. Both of those are clue to allergies. Are you aware of any . . . or do you usually have problems like these at certain times of the year?
Patient: I hadn’t thought of it. (Sounds interested.)
Practitioner: Does anyone in your family have allergies?
Patient: Maybe. I think my mom takes some medicine for allergies sometimes.
Practitioner: Is there anyone at home or at school with symptoms similar to yours?
Patient: Oh yeah. This is really going around at school. Everyone’s sick!
Practitioner: Have you ever had these kind of symptoms before? And, if you have, what was done and did you get better?
Patient: A couple of times, though my throat doesn’t hurt as bad as when I was a little kid. My mom took me to the doctor, and he gave me some medicine. I got well.
Practitioner: Thanks, is there anything else that I should know? Or do you have questions about anything else?
Patient: No, that’s all. (Long pause) I did have one question, but it can wait for another time.
Practitioner: Hum. Is it related to what you’ve already told me about?
Patient: No ma’m, not really.
Practitioner: Jason, do you smoke – or do drugs?
Patient: No way, I’m straight-edge!
Practitioner: Oh – you mean that you don’t do either of those things?
Patient: Yeah.
Practitioner: All right then Jason, let’s look you over. Will you sit on the end of this table – it’ll be easier for me to examine you. If you happen to think of what you wanted to ask – and feel that you can trust me – I’ll be happy to help you if I can. Or if you would be more comfortable talking with a man, I’ll ask one of the other providers to come in.
Patient: Okay.
LATER....
Practitioner: Justin, I’ve finished examining you. We will talk about what you need to do to get better so that you can be in the skateboarding contest this weekend. Have you thought about your question? Would you like to talk with me or one of the men providers about something else?
Patient: Well . . . I’d just like to ask you a question. Then if there is an exam that needs to be done, I’d like one of the men doctors to do it. Is that okay?
Practitioner: Of course, that sounds like a good idea. What’s your question?
Patient: (Hesitantly) Sometimes I wake up all wet – I didn’t pee or anything – I know that. I’ve heard of wet dreams – and I’m pretty stiff when it happens. But what I want to know – is there anything wrong?
Practitioner: Oh, I see. Did you talk with your dad or mom about this?
Patient: No, they don’t know. I do my own laundry.
Practitioner: There probably isn’t anything wrong. We could do a urine test just to be sure you don’t have some kind of infection. We have some printed material about the changes that happen in your body as you go into puberty – as your body becomes more mature. That’s what is happening to you. I’ll give it to you before you leave. You could read it, and then make an appointment with one of the male providers to talk about this if you are still worried. Does that sound okay?
Patient: Yeah – thanks.