S.O.A.P Note Bobby Kauk Completed by: Marissa Huettman
Subjective:
CC: Bobby Kauk is a 18 year-old male who presents to college urgent care “feeling really sick”
with fatigue, cough and shortness of breath.
HPI:
Pt reports feelings like he had the “flu” 10 days ago with relief of symptoms but then 4 days ago
notes sudden onset of a productive fever, cough, fatigue and myalgias. He states a fever of 104 F
at home accompanied by chills and has been taking Ibuprofen 400mg frequently, last dose being
4 hours prior to arrival. His cough is productive with thick green to yellow sputum and he feels
as if it is coming from his lungs. His cough has no pattern and he has tried cough syrup with no
relief. He notes body aches and fatigue that feels mild throughout his body and rest has made
this better. Three days prior to his visit he also notes new onset of chest pain at the 6-8 ribs mid
axillary line. He states that this chest pain worsens from a 2/10 with shallow breathing to a 7-
8/10 upon coughing. He states the chest pain feels like a stab or an ache. Not coughing makes
m
er as
his chest pain better. He also states he recently noticed shortness of breath with minimal effort,
such as walking around his home or going up stairs. He states this is abnormal for him. Pt states
co
eH w
he has not been around anyone with similar symptoms, although he does live in campus
housing.
o.
rs e
PMH: Mononucleosis as a senior in high school and childhood asthma that has since resolved
ou urc
Surgical: Denies
SH:
Marital Status: Single
o
Housing: Campus housing, Rangler Hall Dorms
aC s
Employment: Student
vi y re
Hobbies/physical activities: N/A
Recent Travel: Denies
Pets: Denies
Military Experience: Denies
ed d
Diet: N/A. No recent change
ar stu
Smoking: Denies history
EtOH: Occasional drinking
Recreational substance use (past and present): Denies
is
Sexual History: Not sexually active
FH: Father, 57, good health. Mother 58, Hypertension
Th
Accidents/Injuries: Denies
Hospitalizations: Denies
Medications: Ibuprofen OTC, As needed for fever and myalgias. Last dose 400 mg 4 hours PTA
sh
Allergies: Denies
Immunizations: +Denies receiving Influenza vaccine this year
ROS: Limited due to problem visit
General: +Fatigue, Fever Denies: Usual weight, recent weight change, weakness, , night sweats,
anorexia, malaise
Head: Denies: Headache, head injury
This study source was downloaded by 100000825079977 from CourseHero.com on 08-02-2021 05:32:12 GMT -05:00
https://www.coursehero.com/file/80852134/Bobby-Kauk-SOAP-note-Huettmandocx/
Subjective:
CC: Bobby Kauk is a 18 year-old male who presents to college urgent care “feeling really sick”
with fatigue, cough and shortness of breath.
HPI:
Pt reports feelings like he had the “flu” 10 days ago with relief of symptoms but then 4 days ago
notes sudden onset of a productive fever, cough, fatigue and myalgias. He states a fever of 104 F
at home accompanied by chills and has been taking Ibuprofen 400mg frequently, last dose being
4 hours prior to arrival. His cough is productive with thick green to yellow sputum and he feels
as if it is coming from his lungs. His cough has no pattern and he has tried cough syrup with no
relief. He notes body aches and fatigue that feels mild throughout his body and rest has made
this better. Three days prior to his visit he also notes new onset of chest pain at the 6-8 ribs mid
axillary line. He states that this chest pain worsens from a 2/10 with shallow breathing to a 7-
8/10 upon coughing. He states the chest pain feels like a stab or an ache. Not coughing makes
m
er as
his chest pain better. He also states he recently noticed shortness of breath with minimal effort,
such as walking around his home or going up stairs. He states this is abnormal for him. Pt states
co
eH w
he has not been around anyone with similar symptoms, although he does live in campus
housing.
o.
rs e
PMH: Mononucleosis as a senior in high school and childhood asthma that has since resolved
ou urc
Surgical: Denies
SH:
Marital Status: Single
o
Housing: Campus housing, Rangler Hall Dorms
aC s
Employment: Student
vi y re
Hobbies/physical activities: N/A
Recent Travel: Denies
Pets: Denies
Military Experience: Denies
ed d
Diet: N/A. No recent change
ar stu
Smoking: Denies history
EtOH: Occasional drinking
Recreational substance use (past and present): Denies
is
Sexual History: Not sexually active
FH: Father, 57, good health. Mother 58, Hypertension
Th
Accidents/Injuries: Denies
Hospitalizations: Denies
Medications: Ibuprofen OTC, As needed for fever and myalgias. Last dose 400 mg 4 hours PTA
sh
Allergies: Denies
Immunizations: +Denies receiving Influenza vaccine this year
ROS: Limited due to problem visit
General: +Fatigue, Fever Denies: Usual weight, recent weight change, weakness, , night sweats,
anorexia, malaise
Head: Denies: Headache, head injury
This study source was downloaded by 100000825079977 from CourseHero.com on 08-02-2021 05:32:12 GMT -05:00
https://www.coursehero.com/file/80852134/Bobby-Kauk-SOAP-note-Huettmandocx/
