Primary Health of Acute Clients

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

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