BOBBY KAUK SOAP NOTE
2026 UPDATE
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 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: +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
, 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), sinus
trouble, 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 dangles feet 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 Air
Ht: 6ft 1 inch
2026 UPDATE
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 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: +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
, 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), sinus
trouble, 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 dangles feet 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 Air
Ht: 6ft 1 inch
