Jonathan C. Sewall

Roger is a 22-year old college student who reports three days of elevated temperature, runny nose, sore throat, cough and fatigue along with difficulty breathing. The doctor examines him and finds him to have a temperature of 100.6F, normal respiratory rate, with inflammation of the pharynx. He is found to have an infection with a virus. He is told to keep up with the fluids, nutrition, and rest that he should be well within the week.

1. Which of the above are symptoms? (Patient) * Three days of elevated temperature. * Runny nose. * Sore throat. * Fatigue along with difficulty breathing.

2. Which of the above are signs? (Doctor, RN)
- Temperature of 100.6*F.
- Normal respiratory rate.
- Inflammation of the pharynx.

3. Is this an acute or chronic condition?
-Acute condition.

4. What is the diagnosis?
-Infection with a virus.

5. What is the prognosis?
- Keep up with fluids, nutrition and rest.
- He will recover within a week time frame.

6. Write this as a SOAP note?
S-(subjective)
-Patient states having “three days of elevated temperature, runny nose, sore throat, cough and fatigue along with difficulty breathing”
O-(objective)
-Temperature at 100.6* with normal respiratory rate. Inflammation of the pharynx was found.
A-(assessment)
-Infection with a virus.
P-(plan)
-Keep up with fluid, nutrition, and rest.

Ken is a 78-yearold gentlemen who reports increasing difficulty breathing over the last three months. He also complains of chest pain when he does small amount of exercise. His doctor is concerned that this may be cause by coronary artery disease. The doctor performs a physical exam showing normal temperature, heart rate, and respiratory rate. Cardiac testing shows that he does have blockages due to hardening of the arteries in his heart. He is then placed on medication to