nursing -soap note

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-adults-

following-acute-viral-illness

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