What is a sample SOAP note for a patient presenting with seasonal flu?

SOAP Note Example for Seasonal Influenza

Subjective (S)

Chief Complaint:

• "I have fever, cough, and body aches for the past 2 days" 1

History of Present Illness:

• Acute onset of symptoms [duration] days ago 1
• Fever (document subjective fever even if not measured at home) 2
• Cough (present in 90% of influenza cases) 2
• Myalgias/body aches 1
• Headache 1
• Fatigue/malaise 3
• Sore throat (present in only 21% of hospitalized influenza patients, so absence does not rule out influenza) 2
• Chills 3
• Nasal congestion or rhinorrhea 1

Important Negatives to Document:

• Shortness of breath or dyspnea 4
• Chest pain 4
• Confusion or altered mental status 4

Past Medical History:

• Chronic conditions (COPD, asthma, heart failure, diabetes, immunocompromised state) - these are high-risk factors 1
• Immunization status (influenza vaccine this season) 1
• Recent sick contacts or exposure to confirmed influenza 1

Medications:

• Current medications, particularly immunosuppressants 1
• Recent acetaminophen or antipyretic use 2

Objective (O)

Vital Signs:

• Temperature (document even if afebrile, as 40% of hospitalized influenza patients may not have documented fever ≥37.8°C) 2
• Heart rate 4
• Respiratory rate 4
• Blood pressure 4
• Oxygen saturation on room air 1, 4

Physical Examination:

• General appearance: assess for respiratory distress, mental status 4
• HEENT: pharyngeal erythema, nasal discharge 1
• Lungs: clear to auscultation vs crackles/rales (suggesting pneumonia), wheezing (suggesting bronchospasm or underlying reactive airway disease) 1, 4
• Cardiovascular: regular rate and rhythm, no murmurs 4
• Neurologic: alert and oriented vs confusion 4

Diagnostic Testing (if indicated):

• Nasopharyngeal swab for influenza testing (collect within 4 days of symptom onset for optimal yield) 1
  • Rapid molecular assay preferred over rapid antigen test 1
  • Note: Rapid antigen tests have only 10-80% sensitivity; negative results do not rule out influenza 5
• Chest X-ray if pneumonia suspected (dyspnea, hypoxia, or abnormal lung exam) 1, 6
• Pulse oximetry - if <92%, obtain arterial blood gas 1, 5
• Complete blood count - WBC >8000 associated with lower probability of influenza 7
• Blood cultures if severe illness or pneumonia suspected 1, 6
• Pneumococcal and Legionella urine antigens if pneumonia present 1

Assessment (A)

Primary Diagnosis:

• Influenza A (or B), uncomplicated 1, 3
  • OR: Influenza-like illness (ILI) - defined as fever ≥37.8°C AND cough or sore throat 1
  • Note: Only 51% of hospitalized influenza patients meet CDC ILI criteria 2

Severity Assessment (if pneumonia present):

• Calculate CURB-65 score for pneumonia severity: Confusion, Urea, Respiratory rate, Blood pressure, age ≥65 6, 4
  • Score 0-1: outpatient management 6
  • Score 2: consider short inpatient stay 6
  • Score ≥3: severe pneumonia requiring hospitalization 6, 4

Risk Stratification:

• High-risk patient (age ≥65, chronic cardiopulmonary disease, immunocompromised, pregnant) vs low-risk 1

Differential Diagnoses:

• COVID-19 8
• Bacterial pneumonia 1, 6
• Acute bronchitis 8
• Other viral respiratory infections 8

Plan (P)

Antiviral Therapy:

• Oseltamivir 75 mg PO twice daily for 5 days (start immediately, do not wait for test results in high-risk patients or those with severe illness) 4, 9
  • Initiate even if >48 hours from symptom onset in hospitalized or severely ill patients 4
  • Dosing adjustments required for renal impairment 9
  • Alternative agents: zanamivir, peramivir, or baloxavir 5

Antibiotic Therapy (if pneumonia suspected):

• Non-severe pneumonia (outpatient): Amoxicillin high-dose OR macrolide (if penicillin-allergic) 6
• Severe pneumonia (ICU): β-lactam (ceftriaxone, cefotaxime, or ampicillin-sulbactam) PLUS azithromycin or respiratory fluoroquinolone 6, 4
• Administer first dose in emergency department if hospitalized 6, 4

Supportive Care:

• Oxygen therapy to maintain SpO2 ≥92% 1, 6, 4
• Antipyretics (acetaminophen or ibuprofen) for fever and myalgias 2
• Adequate hydration - assess for volume depletion and provide IV fluids if needed 6, 4
• Rest and symptomatic management 3

Monitoring:

• Outpatient: Monitor temperature, respiratory rate, oxygen saturation at least twice daily 1, 4
• Inpatient: Continuous monitoring of vital signs, mental status, oxygen requirements 1, 4
• Reassess if not improving within 72 hours 6

Disposition:

• Discharge home if: low-risk patient, no respiratory distress, SpO2 >92% on room air, able to maintain oral intake, no signs of severe illness 6, 4
• Admit to hospital if: CURB-65 ≥2, hypoxia, severe respiratory distress, hemodynamic instability, or ≥2 of: temperature >37.8°C, HR >100/min, RR >24/min, SBP <90 mmHg, SpO2 <90%, inability to maintain oral intake, abnormal mental status 6, 4
• ICU admission if: respiratory failure, septic shock, severe hypoxemia despite maximal oxygen, progressive hypercapnia, or altered mental status 4

Patient Education:

• Infection control measures: hand hygiene, respiratory etiquette, isolation from high-risk contacts 1, 8
• Return precautions: worsening dyspnea, chest pain, confusion, inability to maintain hydration 4
• Expected duration of illness: 5-7 days for uncomplicated influenza 3
• Chemoprophylaxis for high-risk household contacts (oseltamivir 75 mg once daily for 10 days) 1, 9

Follow-up:

• Recheck in 24-48 hours if outpatient management 6
• Chest X-ray at 6 weeks if pneumonia present and symptoms persist 1