Running Note: SOAP NOTE: INFLUENZA (FLU) 1
SOAP Note: Influenza (FLU)
Identifying Data and Chief Complain
A 16yearold female, Puertorrican and single, comes to the clinic with her mother for an
acute visit complaining of having chills, cough, headache, myalgia, malaise, fatigue, weakness,
nausea, nasal stuffiness, sore throat and fever. Mother explains that is worried because some
influenza cases have been reported in her daughter’s school. Patient refers that “I started feeling
really bad in school yesterday after lunch break with headache, fever, nasal stuffiness, chills, and
body and throat pain. Today I feel worse than yesterday. I am feeling really tired and weak. I do
not have appetite and have nausea most of the time. I could not go to school today and I want to
feel good, because I am a volleyball player and I have a tournament next weekend.” Mother
informs that the patient had a fever of 39.7ºC before the today clinic visit. The mother is giving
her daughter two tabs of Tylenol 500 mg every four hours for fever and pain, but the patient does
not feel better and the fever is not well controlled with the Tylenol. Mother informs that the
patient is a healthy adolescent and does not have chronic conditions. Patient has a private
medical insurance, Triple S. Her father is the primary cardholder.
Subjective Symptoms
1. “started feeling really bad in school with headache, fever, cough, nasal stuffiness, chills,
and body and throat pain.”
2. “feeling really tired and weak.”
3. “no appetite, having nausea most of the time”.
Subjective Data
Past medical history (PMH): Mother informs that the patient is a healthy child and had varicella
at six years old. LMP was on February 3, 2016. Mother informs that did not have complications
, SOAP NOTE: INFLUENZA (FLU) 2
during gestation and delivery of the patient. Patient exercises every day, she is a volleyball player.
Mother denies patient chronic diseases. Immunizations are up to date, including HPV. Patient is
not immunized to the 2015-2016 influenza vaccine.
Family history: Mother is a 39-year-old woman with no history of chronic diseases. Father is a
40-year-old man with no history of chronic diseases. Patient has a 13-year-old healthy sister. Her
grandfather from the father’s side is a 62-year-old man with hypertension. Her grandmother from
the father’s side is healthy 59-year-old woman. Her grandfather from the mother’s side history is
unknown. Her grandmother from the mother’s side is a 70-year-old woman with DM2 and Htn.
Past social history (PSH): Patient refers does not have toxic habits in the past and present time.
She is practical Christian. She denies sexual activities. Patient lives with parents and a younger
13-year-old sister. She is in 11th grade of high school in a private school of the Metropolitan Area.
She exercises daily, is a volleyball player in her school team for the last five years.
Immunization: Vaccines are up to date, including HPV. Not influenza immunization for this
current season (2015-2016).
Allergies: No known allergies (NKA).
Surgical history: No surgeries history.
Medication history: At this moment, patient’s mother is administering her two tab of Tylenol
500 mg every four hours, for pain and fever. No other medication history.
Subjective Symptoms and Review of Systems (ROS)
Constitutional: Patient reports chills, cough, headache, myalgia, malaise, fatigue, weakness,
nausea, nasal stuffiness, sore throat and fever from yesterday. Patient denies weight changes.
Skin: Patient indicates that does not have lesions, dry skin, pruritus, no nodules, no new moles,
no dry hair and no eczema. Patient reports some acne during her menstrual cycle.
SOAP Note: Influenza (FLU)
Identifying Data and Chief Complain
A 16yearold female, Puertorrican and single, comes to the clinic with her mother for an
acute visit complaining of having chills, cough, headache, myalgia, malaise, fatigue, weakness,
nausea, nasal stuffiness, sore throat and fever. Mother explains that is worried because some
influenza cases have been reported in her daughter’s school. Patient refers that “I started feeling
really bad in school yesterday after lunch break with headache, fever, nasal stuffiness, chills, and
body and throat pain. Today I feel worse than yesterday. I am feeling really tired and weak. I do
not have appetite and have nausea most of the time. I could not go to school today and I want to
feel good, because I am a volleyball player and I have a tournament next weekend.” Mother
informs that the patient had a fever of 39.7ºC before the today clinic visit. The mother is giving
her daughter two tabs of Tylenol 500 mg every four hours for fever and pain, but the patient does
not feel better and the fever is not well controlled with the Tylenol. Mother informs that the
patient is a healthy adolescent and does not have chronic conditions. Patient has a private
medical insurance, Triple S. Her father is the primary cardholder.
Subjective Symptoms
1. “started feeling really bad in school with headache, fever, cough, nasal stuffiness, chills,
and body and throat pain.”
2. “feeling really tired and weak.”
3. “no appetite, having nausea most of the time”.
Subjective Data
Past medical history (PMH): Mother informs that the patient is a healthy child and had varicella
at six years old. LMP was on February 3, 2016. Mother informs that did not have complications
, SOAP NOTE: INFLUENZA (FLU) 2
during gestation and delivery of the patient. Patient exercises every day, she is a volleyball player.
Mother denies patient chronic diseases. Immunizations are up to date, including HPV. Patient is
not immunized to the 2015-2016 influenza vaccine.
Family history: Mother is a 39-year-old woman with no history of chronic diseases. Father is a
40-year-old man with no history of chronic diseases. Patient has a 13-year-old healthy sister. Her
grandfather from the father’s side is a 62-year-old man with hypertension. Her grandmother from
the father’s side is healthy 59-year-old woman. Her grandfather from the mother’s side history is
unknown. Her grandmother from the mother’s side is a 70-year-old woman with DM2 and Htn.
Past social history (PSH): Patient refers does not have toxic habits in the past and present time.
She is practical Christian. She denies sexual activities. Patient lives with parents and a younger
13-year-old sister. She is in 11th grade of high school in a private school of the Metropolitan Area.
She exercises daily, is a volleyball player in her school team for the last five years.
Immunization: Vaccines are up to date, including HPV. Not influenza immunization for this
current season (2015-2016).
Allergies: No known allergies (NKA).
Surgical history: No surgeries history.
Medication history: At this moment, patient’s mother is administering her two tab of Tylenol
500 mg every four hours, for pain and fever. No other medication history.
Subjective Symptoms and Review of Systems (ROS)
Constitutional: Patient reports chills, cough, headache, myalgia, malaise, fatigue, weakness,
nausea, nasal stuffiness, sore throat and fever from yesterday. Patient denies weight changes.
Skin: Patient indicates that does not have lesions, dry skin, pruritus, no nodules, no new moles,
no dry hair and no eczema. Patient reports some acne during her menstrual cycle.
