Case #2 SOAP note Marvin Webster

“I feel awful...I’m exhausted, short of breath, my fever is getting worse.” HPI: Marvin C. Webster is an 18 yr old male who recently had the influenza virus two weeks ago which resolved, and today presents with a four-day history of sudden onset fever 103.2, with chills, rigors, myalgia, productive cough without wheezing, fatigue, and sharp right-sided pleuritic chest pain that is aggravated with coughing and breathing. He reported a fever of 104 last night and took OTC Ibuprofen with no significant improvement in his symptoms. He complains of a productive cough with green/yellow sputum with no relief after taking cough syrup. Pt denies any recent travel or sick contacts. The patient reports he takes no daily prescription medications or additional OTC medications.