NURSING 595 Bobby Kauk Soap Note Case CC : “Feeling Really Sick” 2 DIFFERENT VERSIONS OF THE ANSWER COMPLETE (EXPERT FEEDBACK)2023 UPDATE

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 notessudden 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 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 he has not been around anyone with similar symptoms, although he does live in campus housing. PMH: Mononucleosis as a senior in high school and childhood asthma that has since resolved Surgical: Denies SH: Marital Status: Single Housing: Campus housing, Rangler Hall Dorms Employment: Student Hobbies/physical activities: N/A Recent Travel: Denies Pets: Denies Military Experience: Denies Diet: N/A. No recent change Smoking: Denies history