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Patient Initials: Pt. Encounter Number: Encounter Number:
Date: Age: Sex:
Allergies: Advanced Directives: None
SUBJECTIVE
CC: “Mother: My son has a dry cough, sore throat, diarrhea, fever, and general body tiredness that has been getting
HPI: A 17-year-old male is brought to the clinic by his mother. Patient mother reports patient came back to Florida
from New York where he had gone to visit his grandmother. The patient has been wearing a mask, washing hands,
and sanitizing frequently, though he sometimes wears the mask wrongly, leaving his noses exposed. Despite taking
OTC Tylenol to bring down the fever, the condition has continued to worsen as the days pass by, necessitating the
visit to the clinic.
Onset: 10 days ago
Location: Respiratory system, gi,
Duration: 13 days now
Characteristics: Dry cough, shortness of breath, sore throat, and fatigue, fever.
Aggravating Factors: None.
Relieving Factors: None
Treatment: OTC Tylenol
Current Medications: Tylenol
PMH
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Screening Hx/Immunizations Hx: Up to date
Hospitalizations: None
Surgeries: None
, COVID-19 SOAP NOTE LATEST UPDATE RATED A+
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Family History:
Mother: Diabetes, aged 40 years.
Father: Hypertension, aged 45 years.
Sister: Healthy, aged 21 years.
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