Focused SOAP Note Health, Medicine, Nursing Essay Paper

Focused SOAP Note: Sample
Student Name
Course
Department
Professor
Date
Focused SOAP Note
Patient Information:
LB, 58-year-old White Male
S.
CC (chief complaint): Cough
HPI: LB is a 58-year-old white male who came to the clinic complaining of an intermittent cough that has been going on for the last four days. The cough started as a dry cough, but in the last two days, it has been a productive cough. The patient produces pale-yellow phlegm when he coughs and he feels tired. There is no specific time as to when the cough gets worse, but he claims to have used Tylenol occasionally and it relieved the cough.
Current Medications: The patient is currently on lisinopril 20 mg daily; metformin 500 mg twice daily medications.
PMHx: History of Hypertension and Diabetes Mellitus Type 2. He admits he has not been going to his caregiver on a regular basis (thinks last time he went was about 7 months ago) but his provider had refilled his meds for a year, so he has not run out of them.
Soc & Substance Hx: The patient admits to being a smoker and has been smoking the 40 pack cigarettes for the past one year. He, however, refutes taking alcohol of any other drugs.
ROS
* GENERAL: Ht: 5’4”; Wt: 190 lbs; BP: 150/94; P 88 R 26; Temp: 101.0 oral Pulse ox 96%
* HEENT: No visible head injuries, vision is okay, no hearing issues, no runny nose, uncontrollable coughing established.
* SKIN: Okay, with no rash or significant injury marks. No itching was reported, as well.
* CARDIOVASCULAR: No discomforts in the chest, and no edema.
* RESPIRATORY: The breathing pattern is okay. Signs of possible blockage due to sputum secretions.
* GASTROINTESTINAL: No abdominal pains or blood in the stool.
* GENITOURINARY: No discomforts when passing urine and no odor or odd color.
* NEUROLOGICAL: No headache, dizziness, or even numbness. Bowel control is okay.
* MUSCULOSKELETAL: No pain in the muscles and bones.
* HEMATOLOGIC: No signs of anemia or bleeding. However, high blood pressure is evident. The patient is on prescription drugs for the same.
* LYMPHATICS: No enlarged lymph nodes.
* ENDOCRINOLOGIC: No reports of unexplained sweating or uneven body temperatures.
O.
1 History Questions:
How long have you had the cough?
Did your cough start with any form of an illness?
Do you get the urge to cough especially after meals?
What time of the day does the cough get worse?
Do you cough all of the time or only during or after activity?
Do you cough up mucus or is it just dry?
If you cough up mucus, what color is it?
Do you see blood shots in the coughed out mucus?
Do you experience chest discomfort when coughing?
Have you been diagnosed with pneumonia or whooping cough in the recent past?
Do you smoke tobacco or marijuana? If not, do you vape? Any other intoxicating drugs?
Do you have any allergies that may trigger a cough?
How does you coughing affect your ability to work or engage in other activities? Do you experience difficulty when breathing?
2 Physical Exam
The physical exam tests to obtain for this kind of cough might include blood tests, sputum tests, and imaging tests. Other tests might include meth...