Pneumonia_ SOAP note Case Analysis – Cough – Primary Care Setting

Pneumonia_ SOAP note Case Analysis – Cough – Primary Care Setting

SOAP Note

Patient Initials: J.K.                Age: 37 years old           Race: Hispanic              Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): “I have a cough.”

History of Present Illness (HPI): J.K. is a 37-year-old Hispanic female who has visited the clinic for a medical check-up after developing a cough. She has reported a dry cough that worsened when lying down. The cough is non-productive. Patient J.K. lastly saw a doctor for a tooth extraction. She reported an MI last June but there is no record of hospitalization, so it can be reported as a ‘cardiac event’. During her last visit to the hospital, the patient’s the cardiologist only prescribed enalapril and aspirin.

PMHx: J.K. is obese but she denies any diagnosis with other chronic conditions. She reported an MI last June but there is no record of hospitalization.

Past Surgical Hx: Denies surgical history.

Social Hx: J.K. is not employed at the moment. She is happily married and sexually active. Denies smoking, alcohol consumption, and the use of illicit drugs such as cocaine and heroin. According to J.K., she is physically active and usually performs activities of daily living on her own. She hardly engages in exercise activities outside the house.

Medications:

• Enalapril 1X day
• Aspirin 1X day
• COVID vaccinated
• Amoxicillin prophylactic for a tooth extraction

Sexual/Reproductive History: J.K. has 2 children. She had her children through a normal delivery. Denies reproductive issues.

Significant Family History: J.K.’ sister is asthmatic. Her parents are still alive. The father was diagnosed with hypertension two months ago. Her two children are healthy.

Immunization History: J.K. reports receiving all her immunizations as required.

Allergies: Denies drug and food allergies.

Review of Systems (ROS):

General: No fever, no other symptoms.

HEENT:

Head: Denies physical head injury. Does not report a mild headache.

Eyes: Denies changes in vision. Visual acuity is good. Conjunctiva is moist and pink. The sclera is white.

Ears: No hearing problems reported. Denies ear pain.

Nose: Denies nasal congestion. No runny nose reported. Denies pain in the nose.

Throat: Reports a dry cough, non-productive but worsens when lying down.

Neck: Does not report neck-related pain reported.

Respiratory: Denies tightness of the chest. Reports breathing difficulties. Denies having pain on the chest.

Cardiovascular/Peripheral Vascular: Denies chest tightness.

Gastrointestinal: No stomachache, no constipation, no abdominal pain.

Genitourinary: Does not report pain in the genitals. No vaginal itching. No pain during urination. Denies abnormal vaginal discharge. Does not report abnormal urination frequency.

Musculoskeletal: Does not report joint pain. No overall body weakness.

Neurologic: Denies headache. Does not report numbness on fingers and toes.

Psychiatric: Denies occasional seizures, issues with memory, vision changes, or feelings of hopelessness.

Skin: Denies itchiness or redness on the skin. No skin rashes reported.

Hematologic: Does not report anemia or any other blood-related disorders.

Endocrine: No excessive thirst, no frequent urination. Denies an abnormal increase in urine volume. No weakness, no abnormal sweating at night.

OBJECTIVE DATA:

Physical Exam:

Vital signs:

Height: 48.6 inches; Weight: 127 lb; RR: 18; HR: 82; BP: 130/80; Oxygen saturation: 99%; Temperature: 36 degrees Celsius.

General Appearance: J.K. is attentive and neatly dressed. She can describe her symptoms and is able to respond to questions properly. She