adult soap note

Initials: G.B.
Age: 61 years
Race: Caucasian
Gender: Female
Marital Status: Married
CHIEF COMPLAINT (CC): Patient complains of “cough and congestion for 2 weeks.”
HISTORY OF PRESENT ILLNESS (HPI): Patient c/o dry cough x 2 weeks. Patient states she
just got back from a cruise and was in the casinos on the ship a lot. She thought the cigarette
smoke could have been making her cough but it is not any better. She now feels congestion in
her chest and c/o hoarseness and expiratory wheezing.
location: congestion in chest
quality: patient describes a feeling of tightness in her chest
severity: patient rates pain a “3” on a scale from 1-10. She states her cough is
constant and is continuing to worsen
timing: symptoms started 2 weeks ago
setting: patient states her symptoms started while she was on a cruise in the
ship’s casinos
alleviating and aggravating factors: cough is worse at night, with any physical
exertion, or when she gets hot. She states she still coughs at rest but it is
somewhat better.
associated signs and symptoms: hoarseness and expiratory wheezing
Allergies: NKDA
Current medications: citalopram 40 mg tablet, levothyroxine 50 mcg tablet,
pantoprazole 40 mg tablet, delayed release
Age/health status: 61 years
Appropriate immunization status: Up to date on all vaccines; Flu vaccine given
November 2013. She states she will be getting the flu and pneumonia vaccines at
her primary physician’s office this fall.
Previous screening tests result: Patient states she had a pap smear and
mammogram in March 2014 and both were reported normal.
Dates of illnesses during childhood: N/A
Major adult illnesses: Patient states she has a history of depression,
hypothyroidism, and GERD
Injuries: N/A
Hospitalizations: No hospitalizations other than when she had a tonsillectomy as
a child
Surgeries: Tonsillectomy at age 10
FAMILY HISTORY (FH): Father has a history of HTN and Type II Diabetes; Mother has a
history of COPD. Patient has 1 sister who has HTN. She does not have any children.
SOCIAL HISTORY (SH): She is married and works as a social worker for DHR. She is
independent with her ADLs and lives with her husband. She states she currently exercises about
3 times per week which includes brisk walking for about 1 mile. She is a former smoker- ½
pack/day but she states she quit 5 years ago. She does drink alcohol occasionally if she is at a
social event. She drinks caffeine (coffee or soda) 1-3 times daily. No illicit drug use.
1. Constitutional symptoms- Patient reports fatigue, fever, and difficulty sleeping
due to coughing. Patient denies chills, malaise, night sweats, unexplained weight
loss or weight gain, loss of appetite.
2. Eyes- Patient denies blurred vision, difficulty focusing, ocular pain, diplopia,
scotoma, peripheral visual changes, and dry eyes. Patient states she does wear
reading glasses. Date of last eye exam was in 2013.
3. Ears, nose, mouth, and throat- Patient reports headaches and hoarseness.
Patient denies vertigo, sinus problems, epistaxis, dental problems, oral lesions,
hearing loss or changes, nasal congestion, sore throat. Date of last dental visit
was about 6 months ago.
4. Cardiovascular- Patient states she exercises about 3 times a week for about 30
minutes to an hour. Patient denies any history of heart murmur, chest pain,
palpitations, dyspnea, activity intolerance, varicose veins, edema. Date of last
EKG and cholesterol level was in March 2014 at her yearly physical and was
reported normal.
5. Respiratory- Patient reports cough, SOB on exertion, difficulty breathing at
times, expiratory wheezing, chest tightness/pain on inspiration, exposure to
secondary smoke. Patient denies history of respiratory infections, exposure to
TB, hemoptysis. Patient states she has never had a chest x-ray. Her last TB skin
test was done in March 2014 for work and it was negative. Patient states she is a
former smoker but quit 5 years ago.
6. Gastrointestinal- Patient reports a history of GERD. She states she was
diagnosed about 1 year ago and it is managed well with protonix. Patient denies
dysphagia, reflux, pyrosis, loss of appetite, bloating, nausea, vomiting, diarrhea,
constipation, hematemesis, abdominal or epigastric pain, hematochezia, change
in bowel habits, food intolerance, flatulence, hemorrhoids. Patient states she
tries to eat healthy, well-balanced meals.
7. Genitourinary- Patient denies urgency, frequency, dysuria, suprapubic pain,
nocturia, incontinence, hematuria, history of stones, vaginal discharge. Patient
states her LMP was about 9 years ago. She does not take any hormone
replacements. Her last pap smear was in March 2014 and was reported normal.
Her last mammogram was in March 2014 and was reported normal.
8. Musculoskeletal- Patient denies back pain, joint pain, swelling, muscle pain or
cramps, neck pain or stiffness, changes in ROM. She states she exercises about 3
times a week. She does wear her seatbelt.
9. Integumentary- Patient denies itching, uritcaria, hives, nail deformities, hair loss,
moles, open areas, bruising. Patient denies breast tenderness, masses, skin
changes. She states she uses sunscreen while outside and inspects her skin
regularly for any changes.
10. Neurologic- Patient reports a headache. Patient denies weakness, numbness,
muscular weakness, tingling, memory difficulties, involuntary movements or
tremors, syncope, stroke, seizures, paresthesias.
11. Psychiatric- Patient reports a history of depression. She was diagnosed in her
late 30s but states it is well controlled with celexa. Patient denies nightmares,
mood changes, anxiety, nervousness, insomnia, suicidal thoughts, exposure to
violence, or excessive anger.
12. Endocrine- Patient reports hypothyroidism. She was diagnosed about 10 years
ago and has been taking levothyroxine to manage it. Patient denies cold or heat
intolerance, polydipsia, polyphagia, polyuria, changes in skin, hair or nail texture,
unexplained change in weight, changes in facial or body hair, changes in hat or
glove size, use of hormonal therapy.
13. Hematologic/lymphatic- Patient denies unusual bleeding or bruising, lymph
node enlargement or tenderness, fatigue, history of anemia, blood transfusions.
Patient is unsure of last HCT result but states all lab work was done at her last
physical in March 2014 and everything was reported to her as “normal”.
14. Allergic/immunologic- Patient denies seasonal allergies, allergy testing,
exposure to blood or body fluids, use of steroids, or immunosuppression in self
or family. She is unsure of her last Hep B vaccine but states she has had one for
1. Constitutional- VS: Temp- 96.8, BP- 124/74, HR- 74, RR- 18, O2 sat- 97%, Height5’5”, Weight- 170 lbs, BMI- 28.29; General Appearance: healthy-appearing, wellnourished, and well-developed . Level of Distress: NAD. Ambulation: ambulating
2. Eyes- sclerae white. Conjunctivae pink. Pupils are PERRL, 3 mm bilaterally.
Extraocular movements intact.
3. Ear, Nose, ThroatEars: external appearance normal-no lesions, redness, or swelling; on otoscopic
exam tympanic membranes clear. Hearing is intact.
Nose: appearance of nose normal with no mucous, inflammation, or lesions
present. Nares patent. Septum is midline.
Mouth: pink, moist mucous membranes. No missing or decayed teeth.
Throat: no inflammation or lesions present. Tonsils WNL- no erythema, ulcers,
masses, exudate, inflammation.
4. Cardiovascular- S1, S2. Regular rate and rhythm, no murmurs, gallops, or rubs
Carotid Arteries: normal pulses bilaterally, no bruits present
Pedal Pulses: 2+ bilaterally
Extremities: no cyanosis, clubbing, or edema, less than 2 second refill noted
5. Respiratory- Even and unlabored. Bilateral expiratory wheezes and fine crackles
in upper lobes on auscultation. Non-productive, hacking cough frequently.
Patient is unable to take a deep breath without coughing. Fremitus is equal and
there is no egophony.
6. Gastrointestinal- abdomen soft and nontender to palpation, nondistended. No
rigidity or guarding, no masses present, BS present in all 4 quadrants
7. Genitourinary- No bladder distention, suprapubic pain, or CVA tenderness.
Pelvic exam was not performed.
8. Musculoskeletal- joint stability normal in all extremities, no tenderness to
9. Integument/lymphaticInspection: No scaling or breaks on skin, face, neck, or arms.
General palpation: no skin or subcutaneous tissue masses present, no
tenderness, skin turgor normal
Face: no rash, lesion, or discoloration present
Lower Extremities: no rash, lesion, or discoloration present
Upper Extremities: no rash, lesion, or discoloration present
10. Neurologic- Grossly oriented x3, communication ability within normal limits,
attention and concentration normal. Sensation intact to light touch, gait within
normal limits
11. Psychiatric- Judgment and insight intact, rate of thoughts normal and logical.
Pleasant, calm, and cooperative. Patient appears to be happy/content.
12. Hematologic/immunologic- Lymph nodes not palpable, no tenderness or masses
present, no bruising
X-RAY, CHEST - 08/26/14
Results: no acute findings that suggest pneumonia
1. Bronchitis
490: Bronchitis, not specified acute or chronic
Patient reports frequent cough that is worse at night, congestion, chest
tightness, hoarseness, expiratory wheezing, headache, and fever. Bilateral
expiratory wheezes and fine crackles in upper lobes on auscultation. Nonproductive, hacking cough frequently. Patient is unable to take a deep breath
without coughing. Fremitus is equal and there is no egophony.
2. 311: Depression
Currently controlled. Patient is taking citalopram 40 mg tablet daily
3. 244.9: Hypothyroidism
Currently controlled. Patient is taking levothyroxine 50 mcg tablet daily
4. 530.81: GERD
Currently controlled. Patient is taking pantoprazole 40 mg tablet, delayed release
Differential Diagnoses:
1. Pneumonia
Patient c/o cough, fever, chest discomfort, crackles and expiratory wheezes on
Refuting data: ruled out with chest x-ray. No shaking chills, rigors, tachycardia,
tachypnea, uneven fremitus, or egophony.
2. Sinusitis
Patient c/o cough, fever, headache, and difficulty breathing at times.
Refuting data: Patient c/o congestion in chest and not sinuses. No sore throat,
purulent nasal drainage, or ear pain.
3. Asthma
Patient c/o chest tightness/congestion, non-productive cough, SOB with
exertion, and wheezing.
Refuting data: Patient’s complaint is acute. PFTs are needed to completely rule
4. Tuberculosis
Patient c/o fatigue and fever, non-productive cough.
Refuting data: No progressive dyspnea, night sweats, weight loss, or hemoptysis.
CXR did not show TB.
Patient c/o cough. Patient has a history of GERD.
Refuting data: No heartburn or other GI symptoms noted.
6. Malignancy
History of smoking. Patient c/o dyspnea at times, cough, fatigue, wheezing, and
chest discomfort/tightness.
Refuting data: No hemoptysis, recurrent respiratory infections, unexplained
weight loss.
1. Cefdinir 300mg capsule; Take 1 capsule by mouth every 12 hours for 10 days
Albuerol sulfate HFA 90mcg/actuation aerosol inhaler; Inhale 2 puffs every 4
Depo-medrol 40mg/ml suspension for injection- IM injection in office
Dexamethasone 4mg/ml injection solution- IM injection in office
Take cefidinir 300mg twice a day for 10 days for the infection. Importance of
finishing antibiotic even if symptoms improve or go away.
Albuterol sulfate inhaler will help with the wheezing.
Steroid shot in office will help control the symptoms and reduce
inflammation so it will be easier for you to breathe.
Continue with smoking cessation and avoid secondary smoke inhalation and
other environmental irritants.
Return to the urgent care clinic or follow-up with your primary physician if
symptoms persist longer than 21 days or if condition worsens.
Health promotion: flu and pneumonia vaccines at next primary physician
appointment this month.
2. Continue taking citalopram 40 mg PO daily to manage depression.
Continue follow-up with primary physician every 3 to 6 months.
3. Continue taking levothyroxine 50 mcg PO daily to manage hypothyroidism.
Continue follow-up with primary physician for lab work to check thyroid levels.
TSH levels should be monitored every 6 to 12 months.
Take levothyroxine with water consistently 30-60 min before breakfast or at
bedtime 4 hours after last meal.
4. Continue taking pantoprazole 40 mg PO daily to manage GERD.
Lifestyle modifications such as avoiding foods that may precipitate reflux and
cause heartburn. Adopt behaviors that may decrease acid exposure such as
weight loss, elevating HOB, and avoiding lying down 3-4 hours after a meal.
Continue follow-up with primary physician.
Study collections