NURSING 595 DIFFERENT VERSIONS OF THE ANSWER COMPLETE (EXPERT FEEDBACK) UPDATE

NURSING 595 DIFFERENT VERSIONS OF THE ANSWER COMPLETE (EXPERT FEEDBACK) UPDATE VERSION A S.O.A.P Note Bobby Kauk 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 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 EtOH: Occasional drinking Recreational substance use (past and present): Denies Sexual History: Not sexually active FH: Father, 57, good health. Mother 58, Hypertension Accidents/Injuries: Denies Hospitalizations: Denies Medications: Ibuprofen OTC, As needed for fever and myalgias. Last dose 400 mg 4 hours PTA Allergies: Denies Immunizations: +Deniesreceiving 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 Eyes: Denies: Vision, glasses/contact lens, date of last eye examination, pain, redness, excessive tearing, double vision (diplopia), floaters (spots in front of eyes), loss of any visual fields, history of glaucoma or cataracts Ears: Denies: Hearing loss, change in hearing, ringing in ears(tinnitus), ear infections Nose and Sinuses: Denies: Frequent colds, nasal stuffiness, hay fever, nosebleeds (epistaxis), sinustrouble, obstruction, discharge, pain, change in ability to smell,sneezing, post-nasal drip, history of nasal polyps Mouth and throat: +Sore Throat Denies: Soreness, dryness, pain, ulcers,sore tongue, bleeding gums, pyorrhea, teeth (caries, abscesses, extractions, dentures), hoarseness, history of recurrent sore throats or of strep throat or of rheumatic fever Neck: +Swollen lymph nodes Denies: Lumps,swollen glands, goiter (thyroid enlargement), pain Pulmonary: +Cough, Dyspnea, Pleuritic Chest pain Denies: change in chronic cough, wheezing, coughing up blood (hemoptysis), blue discoloration of lips or nailbeds (cyanosis), history of exposure to TB, history of a previous TB skin test and the results if done, recurrent pneumonia, history of environmental exposure Cardiovascular: +Chest Pain, Denies: paroxysmal nocturnal dyspnea (abbreviated "PND"; patient will describe shortness of breath that improves when he or she sits up and danglesfeet off the bed), orthopnea (patient has to sleep on pillows to prevent shortness of breath; quantitate by the number of pillows that the patient sleeps on), edema, palpitations, hypertension, known heart disease, history of a murmur, history of rheumatic fever, syncope or near syncope, pain in posterior calves with walking (claudication), varicosities, thrombophlebitis, history of an abnormal electrocardiogram Gastrointestinal: Denies: Trouble swallowing (dysphagia), pain with swallowing (odynophagia), nausea, vomiting, vomiting blood (hematemesis), food intolerance, indigestion, heartburn, change in appetite, sensation of filling up earlier than usual (early satiety),frequency and character (formed vs. loose) of bowel movements, changes in bowel pattern, rectal bleeding, passing black tarry stools (melena), constipation, diarrhea, abdominal pain, excessive belching or passing of gas, hemorrhoids, jaundice, liver or gallbladder problems, history of hepatitis Musculoskeletal: +Myalgias, Denies: Joint pains or stiffness, arthritis, gout, backache, joint swelling or tenderness or effusion, limitation of motion, history of fractures Neurologic: Denies: Fainting, blackouts,seizures, paralysis, local weakness, numbness, tingling, tremors, memory changes, headaches, vertigo or dizziness, muscle atrophy Objective: Well groomed, well developed male, standing. Pt appears to be feeling ill and short of breath but in no apparent distress. He answers all questions appropriately and does not need to stop to catch his breath. Vitals: HR: 120 BP 120/80 RR: 24 Temp: 103.2 F/ 39.6 C Pulse Ox: 91% Room Ai