Soap Note
FNP 593: Primary Health of Acute Clients/Families Across the Lifespan
United States University
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Soap Note #7
Patient ID: JS
Client’s Initials: RH Age: 27 Race: African American Gender: Female Date of Birth:
1/4/1995
Insurance: BC/BS Marital Status: Married
Subjective:
CC: “I have a cough, runny nose, and fever and tested positive for COVID-19 on 1/1/2022, I am
still coughing and have congestion”
HPI: JS is an African American female, a reliable historian who presents to the clinic
unaccompanied, complaining of a productive cough, sore throat, headache, runny nose since
12/28/2022 and tested positive for COVID-19 on 1/1/2022. She has been using Dayquil and
NyQuil to control symptoms. She complains of a worsening cough and continued nasal
congestion, she does not have a fever today but at home temperature had gotten as high as 102.7
degrees. She complains of night sweats and also has headache pain that she rates 5/10 relieved
by Advil. Denies sick contacts or recent travel. Denies seasonal allergies
Past Medical History:
None
Vaccinations:
All Vaccines Current
TDAP (2020), COVID19 (10/2021) Pfizer x 2 doses, influenza vaccine (2021), Eye exam 2021,
Pap smear 2021.
Surgeries: None
Hospitalizations: none
Allergies: NKA
Medications:
Dayquil-4 times a day
Nyquil- pm only
Advil as needed for headache
Family History:
Mother 53-no medical history
Father: unknown
Social History:
denies smoking, illicit drug use, or alcohol use
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Other:
Lives at home with wife and daughter
ROS:
General: Admits to fever 102.7, weakness and fatigue. Denies weight change
Eyes: Denies vision change, corrective lenses, pain
redness, excessive tearing, double vision, blurred vision,
or blindness.
Head: Admits to headaches 5/10. Denies
lightheadedness, or dizziness.
Eyes: Denies vision changes, diplopia, tearing, and scotomata,
Ears: Denies tinnitus, vertigo, discharge, or earache.
Nose: Admits to nasal congestion, drainage, itching, sneezing. Denies nosebleeds.
Throat: Admits to sore throat. Denies difficulty swallowing. Last Dental
exam 2020
C/V: Denies chest pain, palpitations.
Pulmonary: Admits to productive Cough. Denies hemoptysis, dyspnea, wheezing, pleuritic pain
Neuro: Admits to headache. Denies dizziness, focal numbness/weakness, nausea, vomiting.
Lymph: Denies swollen lymph nodes in neck.
Allergy/immunology: Denies seasonal allergies and frequent illness.
Objective
Vital Signs: HR 898 BP 127/74 Temp 100.2 RR 18 SpO2 97% Pain 5/10
Height 66 in Weight 142 BMI: 24.8
Labs 7/09/21:
HbA1c 5.5, LDL 50, HDL 49, Choles 97, TG 68, GFR 110,
Physical Exam
General Survey:
Well-groomed, well-nourished, cooperative reliable historian, dressed appropriately for the
weather in no acute distress
HEENT
Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilat.
Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddened bilat. Nares patent bilat.
No sinus pain upon palpation. Septum midline.
Throat: oral mucosa erythemic, tongue mobile without lesions, tonsils absent. Posterior pharynx
with erythema but no cobblestone appearance.
Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated.
Trachea midline.
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Neuro: Alert and oriented x 4.
Cardio: RRR. Crisp S1 S2 without clicks or murmurs.
Thorax: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use
of accessory muscles, stridor, grunting, or nasal flaring.
Lungs: Wheezing and congestion Bilaterally
Assessment
DX: COVID-19 Pneumonia (UO7.1)
1. COVID-19 Pneumonia most likely diagnosis as evidenced by symptoms and duration
2. Viral Pharyngitis-Not likely as the patient tested Positive for COVID-19
3. Allergic Rhinitis-Not likely as the patient does not have seasonal allergies
Plan
DX: COVID-19 Pneumonia (UO7.1)
A: Observe appearance, negative for cyanosis, Monitor spO2, 97%, Wheezing and
congested lung sounds
B. Treat symptoms with antipyretics and cough medicine, increase fluids
C: Azithromycin 250mg BID x 5 days, Decadron 6mg x 5 days
E. Patient to go to Emergency Department for worsening symptoms or if spO2 drops
below 92%.
(Mikkelsen & Abramoff, 2021).
2: Viral Pharyngitis (J02.9)
A: History and Physical examination,
B: Topical antibiotic or Oral, Augmentin or Cephalexin
C: Oral, Augmentin or Cephalexin
D. Patient to return if signs and symptoms persist or worsen or if new symptoms develop
(Cash, 2021, p. 170-172)
3: Allergic Rhinitis (J30.1)
A: No diagnostic test done
B: Antihistamine, allergy testing and allergy shots if indicated
C: Education on importance of adhering to medication regime
D. Return to if symptoms persist or worsen, or if new symptoms develop,
(Cash 2021, p. 153-156)
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References
Cash, J. C., Glass, C. A., & Mullen, J. (2021). Family practice guidelines (5th ed.). Springer
Publishing Company.
Mikkelsen, M.E., & Abramoff, B. (2021). COVID-19: Evaluation and management of adults
following acute viral illness. UpToDate. Retrieved from
https://www.uptodate.com/contents/covid-19-evaluation-and-management-of-adultsfollowing-acute-viral-illness
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