Week 3 SOAP Note: A 43 year old African American female who presents to the clinic complaining of headache, fever, congestion, and cough. She reports that her symptoms started about one day ago. She reports feeling  pressure in her right ear and face. She rates her pain a five out of 10. She reports being around someone at work who was reportedly sick, but she was unaware of this until the next day. She reports taking Theraflu for her symptoms but she has not seen any improvements. She denies shortness or breath or difficulty breathing when ambulating. She denies a history of asthma, COPD, or CHF. She does however report a history of sinusitis. She reports that she took her Flu shot back in November of 2023.

Week 3 SOAP Note: A 43 year old African American female who presents to the clinic complaining of headache, fever, congestion, and cough. She reports that her symptoms started about one day ago. She reports feeling  pressure in her right ear and face. She rates her pain a five out of 10. She reports being around someone at work who was reportedly sick, but she was unaware of this until the next day. She reports taking Theraflu for her symptoms but she has not seen any improvements. She denies shortness or breath or difficulty breathing when ambulating. She denies a history of asthma, COPD, or CHF. She does however report a history of sinusitis. She reports that she took her Flu shot back in November of 2023.

Week 3 SOAP Note: A 43 year old African American female who presents to the clinic complaining of headache, fever, congestion, and cough. She reports that her symptoms started about one day ago. She reports feeling  pressure in her right ear and face. She rates her pain a five out of 10. She reports being around someone at work who was reportedly sick, but she was unaware of this until the next day. She reports taking Theraflu for her symptoms but she has not seen any improvements. She denies shortness or breath or difficulty breathing when ambulating. She denies a history of asthma, COPD, or CHF. She does however report a history of sinusitis. She reports that she took her Flu shot back in November of 2023.

Patient Information:

Q.T., 43, Female, African American

S.

CC (chief complaint): cough, congestion, and fever

A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”).

HPI: Q.T. is a 43-year-old African American female who presents to the clinic complaining of headache, fever, congestion, and cough. She reports that her symptoms started about one day ago. She reports feeling “pressure” in her right ear and face. She rates her pain a five out of 10. She reports being around someone at work who was reportedly sick, but she was unaware of this until the next day. She reports taking Theraflu for her symptoms but she has not seen any improvements. She denies shortness or breath or difficulty breathing when ambulating. She denies a history of asthma, COPD, or CHF. She does however report a history of sinusitis. She reports that she took her Flu shot back in November of 2023.

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This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: Head

Onset: 3 days ago

Character: Pounding, pressure around the eyes and temples

Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

Timing: After being on the computer all day at work

Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications:

Mirena IUD- birth control

Include dosage, frequency, length of time used, and reason for use; also include OTC or homeopathic products.

Allergies:

NKDA

No known environmental allergies

No known food allergies

Include medication, food, and environmental allergies separately. Include a description of what the allergy is (e.g., angioedema, anaphylaxis, etc.). This will help determine a true reaction vs. intolerance.

PMHx:

Covid Vaccine- 9/10/21, 10/08/21

Tdap- 10/09/21

Influenza- 11/12/23, 09/14/21, 09/10/20

Breast biopsy- 01/01/2008

Endodontic Procedure- 02/01/2018

Include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco, and alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx:

Mother- 65 years old, has a history of hypertension, type 2 diabetes, and breast cancer.

Father- 67 years old, is alive and well with no known medical history.

Maternal grandmother- deceased at 87 years old from natural causes.

Maternal grandfather- 90 years old, with a history of hypertension and hyperlipidemia

Paternal grandmother- 78 years old, has a history of type 2 diabetes.

Paternal grandfather- 83 years old, has a history of asthma, COPD, and hypertension.

Brother- deceased from a heart attack at 40 years old.

Sister- 47 years old has a history of asthma.

Son- 7 years old, alive and well.

Daughter- 3 years old, alive and well.

Identify illnesses with possible genetic predisposition, and contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx:

Breast biopsy- 01/01/2008

Prior surgical procedures.

Mental Hx:

The patient reports having some anxiety when it comes to her job but denies any treatment or taking any medications. She states that it only occurs during the “peak” season at her job. The patient denies any history of self-harm or suicidal or homicidal ideation.

 Diagnosis and treatment. Current concerns: (Anxiety and/or depression).  History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Reproductive Hx:

LMP: 2/12/24- 2/16/24

The patient reports being sexually active with her husband of 10 years. She reports vaginal and oral intercourse with occasional use of toys. She denies currently being pregnant. She reports having two children: a son who is seven years old and a daughter who is three years old. She reports carrying both children full term and a vaginal delivery. She denies any use of condoms or being on birth control.

Menstrual history (date of LMP), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: Denies weight loss, chills, weakness, or fatigue. Reports fever and no appetite.

HEENT: Eyes: Denies visual loss, blurred vision, diplopia, or yellow sclerae. Ears: Denies difficulty hearing, or discharge.  Reports right ear pressure.  Nose: Reports nasal congestion. Denies nasal discharge and difficulty smelling. Throat:  Denies difficulty swallowing and sore throat. Reports cough.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure, or chest discomfort. Denies palpitations or edema.

RESPIRATORY: Denies shortness of breath or sputum. Reports cough. Denies history of asthma, COPD, of CHF. Reports influenza vaccine in November 2023.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. Reports a decrease in appetite.

GENITOURINARY: Denies dysuria or burning during urination. Denies current pregnancy. Last menstrual period 2/12/24-2/16/24.

NEUROLOGICAL: Denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports headache.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression. Reports “a little” anxiety during peak season at her job.

ENDOCRINOLOGIC: Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Reports a family history of diabetes.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Reports being sexually active with husband of 10 years.

ALLERGIES: No history of hives, eczema, or rhinitis. Reports family history or asthma.

O.

GENERAL: Alert and oriented x 4. The patient was groomed appropriately for the weather.

HEENT: Head: normocephalic and atraumatic. Even hair distribution was noted. Ears: The right ear is erythematous and painful to the touch. No discharge was noted. TM is nonpurulent. Eyes: Nose: bilateral nasal turbinates swollen. Nasal passages erythematous. Throat: trachea midline,  uvula midline, no difficulty swallowing.

CARDIOVASCULAR: S1 and S2 heart sounds noted. No peripheral edema was noted.

RESPIRATORY: Lung sounds clear. Equal rise and fall in the chest. No dyspnea was noted during a physical exam.

Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e.) General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)

A.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.