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Soap NoteFNP 593: Primary Health of Acute Clients/Families Across the LifespanUnited States University
Soap Note #7Patient ID: JSClient’s Initials:RHAge: 27Race:African AmericanGender:FemaleDate of Birth:1/4/1995Insurance: BC/BSMarital Status:MarriedSubjective:CC:“I have a cough, runny nose, and fever and tested positive for COVID-19 on 1/1/2022, I amstill coughing and have congestion”HPI:JS is an African American female, a reliable historian who presents to the clinicunaccompanied, complaining of a productive cough, sore throat, headache, runny nose since12/28/2022 and tested positive for COVID-19 on 1/1/2022. She has been using Dayquil andNyQuil to control symptoms. She complains of a worsening cough and continued nasalcongestion, she does not have a fever today but at home temperature had gotten as high as 102.7degrees. She complains of night sweats and also has headache pain that she rates 5/10 relievedby Advil. Denies sick contacts or recent travel. Denies seasonal allergiesPast Medical History:NoneVaccinations:All Vaccines CurrentTDAP (2020), COVID19 (10/2021) Pfizer x 2 doses, influenza vaccine (2021), Eye exam 2021,Pap smear 2021.