create a SOAP note of the case bellow, using the template as guide implementing APA 7 format and scholarly references no older than 5 years

November 16, 2024November 16, 2024 Discipline: Nursing

chief complaint:  “I need cold meds” 

 Patient is a 66 y/o female who came for consultation with acute upper respiratory infection, she complains of cough, nasal congestion, sore throat, chills, headache. On the physical examination there was erythema of the oropharynx, no added respiratory sounds. COVID-19 and flu test performed at office were negative. We started patient on Z-pack, cough syrup, continue with OTC medications. We also ordered a Dexamethasone+ Rocephin IM stat given at office. We will follow up if needed in 2 weeks. 

ICD  J06.9 – ACUTE UPPER RESPIRATORY INFECTION, UNSPECIFIED 

 4170-20241017-001 

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