Can you provide a SOAP note for a healthy 30‑year‑old adult presenting to clinic with fever, chills, sore throat, nasal congestion, cough, myalgias, and headache, who tested positive for SARS‑CoV‑2 (COVID‑19) and influenza A?

SOAP Note: 30-Year-Old with COVID-19 and Influenza Co-infection

SUBJECTIVE

Chief Complaint: Cold and flu symptoms

History of Present Illness:

• 30-year-old previously healthy adult presenting with acute respiratory illness
• Symptoms: fever, chills, sore throat, nasal congestion, cough, myalgias, headache
• Duration of symptoms: [specify days]
• Fever pattern: [document temperature and timing]
• Cough characteristics: nonproductive vs. productive
• Dyspnea: absent (mild illness) vs. present (moderate/severe)
• No chest pain, palpitations, or syncope reported
• Able to maintain oral hydration
• No recent travel or known sick contacts documented

Past Medical History: None
Medications: None
Allergies: NKDA
Social History: [employment, living situation]
Vaccination Status: [COVID-19 and influenza vaccine status - document dates and types]

OBJECTIVE

Vital Signs:

• Temperature: [°F/°C]
• Heart Rate: [bpm]
• Blood Pressure: [mmHg]
• Respiratory Rate: [breaths/min]
• Oxygen Saturation: [%] on room air

Physical Examination:

• General: Alert, appears mildly ill vs. well-appearing
• HEENT: Pharyngeal erythema present/absent, nasal congestion
• Cardiovascular: Regular rate and rhythm, no murmurs
• Pulmonary: Clear to auscultation bilaterally vs. scattered rhonchi; no wheezes, rales, or increased work of breathing
• Extremities: No edema, normal perfusion

Diagnostic Testing:

• SARS-CoV-2 RT-PCR (nasopharyngeal swab): POSITIVE - confirmed acute COVID-19 case 1
• Influenza A/B RT-PCR: POSITIVE for Influenza A - confirmed acute influenza 2
• [If obtained] Chest X-ray: Clear vs. infiltrates
• [If obtained] Basic labs: CBC, CMP, inflammatory markers

ASSESSMENT

Primary Diagnoses:

1. Confirmed acute COVID-19 infection (SARS-CoV-2 positive) 1
2. Confirmed acute influenza A infection 2
3. Mild illness classification - symptoms present without dyspnea or abnormal chest imaging 3

Clinical Significance: Co-infection with SARS-CoV-2 and influenza A occurs and may present with overlapping symptoms including fever, cough, myalgias, and upper respiratory symptoms 4, 5. This patient's clinical presentation is consistent with mild viral respiratory illness without evidence of bacterial co-infection, which occurs in only 3.5% of COVID-19 patients at admission 6. The absence of dyspnea, normal oxygen saturation, and lack of chest imaging abnormalities support outpatient management.

PLAN

Antiviral Therapy

Influenza treatment is indicated and should be initiated immediately:

• Prescribe oseltamivir 75 mg PO BID for 5 days (or alternative neuraminidase inhibitor)
• Most effective when started within 48 hours of symptom onset 2

COVID-19 antiviral consideration:

• For this healthy 30-year-old with mild illness, antiviral therapy (nirmatrelvir/ritonavir or molnupiravir) may be considered but is not mandatory
• Prioritize if patient has risk factors for progression or if within 5 days of symptom onset

Antibacterial Therapy

No antibiotics indicated at this time 6:

• Bacterial co-infection rate is only 3.5% in COVID-19 patients at admission
• No clinical, laboratory, or radiographic evidence of bacterial pneumonia
• Unnecessary antibiotics increase risk of subsequent resistant infections and adverse events

Symptomatic Management 7

Fever and myalgias:

• Acetaminophen 650-1000 mg PO every 6 hours as needed
• Preferred over NSAIDs for COVID-19 patients until more evidence available
• Continue only while symptoms present
• Advise regular fluid intake (up to 2 liters daily) to prevent dehydration

Cough:

• Simple measures first: avoid lying flat (makes coughing ineffective)
• Honey for symptomatic relief (1-2 teaspoons as needed)
• If cough becomes severely distressing: consider short-term codeine linctus or codeine phosphate

Nasal congestion:

• Saline nasal spray
• Decongestants if needed (pseudoephedrine or phenylephrine)

Monitoring and Follow-up

Patient education on warning signs requiring immediate medical attention:

• Difficulty breathing or shortness of breath
• Persistent chest pain or pressure
• New confusion or inability to arouse
• Bluish lips or face
• Inability to maintain hydration

Isolation and infection control:

• Isolate at home for minimum 10 days from symptom onset 8
• Most transmission occurs within first 7 days for both viruses
• Wear mask if around others
• May return to normal activities when fever-free for 24 hours without antipyretics AND symptoms improving

Follow-up:

• Telehealth check-in at 48-72 hours to assess response
• Return to clinic if symptoms worsen or new symptoms develop
• No routine repeat testing needed for clearance in immunocompetent patients

Treatment Escalation Planning 7

Document that patient understands:

• COVID-19 patients can deteriorate rapidly
• If dyspnea, persistent fever >5 days, or worsening symptoms develop, seek immediate evaluation
• Emergency department presentation warranted for severe symptoms

Work/Activity Restrictions

• Remain off work/avoid public spaces during isolation period
• No strenuous exercise until fully recovered and isolation period complete
• Gradual return to normal activity as tolerated after symptom resolution

This patient requires no hospitalization, has low risk for bacterial co-infection, and should respond well to symptomatic management with influenza-specific antiviral therapy. Close monitoring for clinical deterioration is essential given the dual viral infection, though co-infection does not appear to worsen outcomes compared to SARS-CoV-2 alone 4.