SOAP Note for Alternative Residency Assignment Wilkes University, Passan School of Nursing NSG 500: Advanced Health Assessment

Subjective Data Identification: Ms. A is a 40-year-old white female who was born on 08/02/1981. Chief Complaint: “I have been having a cough that seems to be getting worse”. History of Presenting Illness: Ms. A is presenting to the clinic today with complaints of a cough which has been present for the past 10 days. This is the first time Ms. A is being seen for this illness. She reports feeling the cough throughout the lungs and states that green sputum in produced intermittently. Ms. A states that within the past two days the sputum has become blood tinged. The cough is experienced intermittently throughout the day and makes it difficult to sleep at night. There are no identifiable triggers but the patient reports fever up to 100.3 po at the onset of the cough and states she has increased shortness of breath with physical activity. The patient attempted to relieve symptoms with over-the-counter medication such as Robitussion and Mucinex but was unsuccessful. Ms. A reports pain in her left ear which began three days after the cough developed. The patient describes the ear pain as aching, constant, and rates it a 3/10. Ms. A also reports a headache which has been intermittent over the past five days, is a 4/10 in severity, is located at the front of the head, and is somewhat relieved with two regular strength Tylenol. The patient expresses that she has felt slightly more lethargic than usual, and her appetite has been faintly decreased. She denies sore throat, sinus congestion, heart palpitations, chest pain, swelling in the extremities, diarrhea, constipation, significant weight loss or gain, chills, night sweats, and dysuria. The patient states she has not traveled anywhere within the past three months but reports several of her coworkers have recently become ill. Pertinent Medical and Surgical History: Reports only seasonal allergies. Tonsillectomy and adenoidectomy in childhood.