SOAP note along with ROS and Physical

SOAP note along with ROS and Physical exam for a patient that presents with the following: 25-year-old African American female with a 3-day history of rhinorrhea, cough and fever, sudden onset with clear rhinorrhea, nasal congestion, and sore throat. Nonproductive cough coming from down in chest, not throat. Symptoms quickly progressed to include generalized body aches, headache behind bilateral eyes (rates 5 on pain scale), T. max 103. Treating fever and body aches with OTC Ibuprofen (1-2 tabs twice a day as needed) with some relief, Nyquil with no improvement. Cough is intermittent, occurs every few minutes. No change in time of day or positioning. Interfering with activity, sleep, and work attendance. Exposed to ill contacts at her workplace with similar symptoms. Has not seen a provider for current illness. NKDA, no food allergies Meds: OTC Nyquil Q HS prn and OTC ibuprofen 1-2 tablets bid prn X 2 days Hydrochlorothiazide (HCTZ) 25 mg QD No herbals/supplements, pain medication Chronic Illness: Hypertension x 2 years, last follow-up visit 6 months ago Surgeries/Hospitalizations: Tonsillectomy as a child OB;GYN: G1, P1, A0 IUD x 1 year, no menstrual cycles since IUD placement Mental Health Diagnoses/Hospitalizations: None Child, no chronic health problems Mother: living age 55, HTN x 20 years Father: living age 56, Type II Diabetes and Hyperlipidemia x 10 years Brother: living age 30, HTN x 3 years MGM: living age 75, HTN, hyperlipidemia MGF: deceased due to a work accident PGM: living age 76, Osteoporosis, COPD PGF: living age 77, HTN, Type II Diabetes, CVA Employed fulltime at local telemarketing company Completed high school Married, monogamous, lives with husband and 1 child age 5 Smoker 1 ppd x 7 years, does not smoke in the home or vehicle Husband nonsmoker Denies illicit drug use and ETOH Diet: Cooks often, foods high in fat (a lot of fried foods/red meat, few vegetables/fresh fruits Exercise: No formal exercise Stress/social support/hobbies: reports low perceived stress Vital Signs: Temp. 102, B/P 140/90, P 85, RR 20, BMI: 32, Oxygen sats 97% RA

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