Nursing -soap note

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Soap note to rewrite with zero turnit in score. see attachment

Soap Note

FNP 593: Primary Health of Acute Clients/Families Across the Lifespan

United States University

This study source was downloaded by 100000784347808 from on 05-05-2022 15:03:44 GMT -05:00

Soap Note #7

Patient ID: JS
Client’s Initials: RH Age: 27 Race: African American Gender: Female Date of Birth:
Insurance: BC/BS Marital Status: Married


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:

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

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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Lives at home with wife and daughter

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.


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
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.

This study source was downloaded by 100000784347808 from on 05-05-2022 15:03:44 GMT -05:00

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


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


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)

This study source was downloaded by 100000784347808 from on 05-05-2022 15:03:44 GMT -05:00


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


This study source was downloaded by 100000784347808 from on 05-05-2022 15:03:44 GMT -05:00
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