Write a SOAP note for a patient seen in a practicum that required a comprehensive history and physical examination.

Comprehensive Final Note SOAP Nursing Homework

Subjective: Ms. Smith is a 32-year-old female who presents with complaints of fever, chills, and body aches for the past three days. She reports having a sore throat and cough with yellow sputum production. She denies any recent travel, sick contacts, or known exposures to COVID-19. She reports having a history of asthma and seasonal allergies. She states that she has been taking over-the-counter acetaminophen and ibuprofen for her symptoms, with minimal relief. She is concerned that her symptoms are worsening and wants to be evaluated.

Objective: Vital signs: Blood pressure 118/78 mmHg, heart rate 96 beats/min, respiratory rate 20 breaths/min, oxygen saturation 95% on room air, temperature 101.5 F. General: Alert and oriented, appearing ill, in moderate distress due to cough. Head and neck: No significant abnormalities noted on inspection. Pharynx erythematous, with visible exudate. Tonsils 2+ bilaterally. No cervical lymphadenopathy. Chest and lungs: Breath sounds decreased bilaterally, with crackles and wheezing noted. Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses palpable and equal bilaterally. Abdomen: Soft and non-tender. No hepatosplenomegaly or masses palpated. Extremities: Warm and well-perfused, with no edema or cyanosis noted.

Assessment: Ms. Smith is a 32-year-old female presenting with symptoms consistent with acute bronchitis. Her history of asthma and seasonal allergies puts her at increased risk for complications. She has a fever, cough, and pharyngitis with visible exudate. Lung examination reveals crackles and wheezing. A chest X-ray and CBC with differential are ordered to rule out pneumonia and evaluate for leukocytosis.

Plan:

1. Chest X-ray and CBC with differential ordered.
2. Initiate treatment with oral antibiotics, azithromycin 500 mg daily for five days.
3. Recommend frequent coughing and deep breathing exercises to prevent respiratory complications.
4. Prescribe albuterol inhaler as needed for wheezing.
5. Advise Ms. Smith to continue taking over-the-counter acetaminophen and ibuprofen as needed for fever and body aches.
6. Follow-up in two weeks to evaluate response to treatment.

References:

1. O’Brien APRN, L. S., & Black, S. S. (2016). Diagnosing and managing acute bronchitis. American family physician, 94(9), 684-690.
2. Butler, C. C., Hood, K., Verheij, T. J. M., Little, P., Melbye, H., Nuttall, J., … & Cals, J. W. L. (2019). Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. bmj, 364, l236.
3. Wenzel, R. P., Edmond, M. B., & Team, A. (2014). Managing antibiotic resistance. New England Journal of Medicine, 370(8), 786-786.