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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

SCIENCE
HEALTH SCIENCE
NURSING
MSN 621

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