NU 551 SOAP Note Template
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SOAP Note Template
NU 551, 552, 561, 606/607, 621
**Please delete this statement and anything in italics prior to submission to shorten the length of your paper.
Patient Initials _____AB_
Subjective Data: (Information the patient tells you regarding themselves: Biased Information):
Chief Compliant: “I get short of breath and cough when running”
History of Present Illness: onset approximately 2 years ago when running in the cold weather. Getting worse now with cough. Denies mucous production, CP, N/V, dizziness, LOC. Wet, cold weather seems to make it worse, has tried OTC “inhaler” (unsure of name), cough medication, allergy medications
PMH/Medical/Surgical History: “asthma as a child”, UTD with routine adult immunizations, no routine medications, no surgeries, hospitalizations, states stable mental health, in monogamous relationship x 20 years, no injuries, no hospitalizations, no surgeries.
Significant Family History: Married x 20 years, 2 children, spouse alive and well, parents alive and well, one sibling – deceased of CV disease at age 45.
Social History: neg hx tobacco use, lives with spouse and school age children, no STD hx/concerns, sexual function is “fine”. Working full time in job that is “ok”.
Sexual History: lifetime monogamous partner
Gynecological History male pt
Pediatrics NA
Review of Symptoms: General: denies other symptoms except SOB and cough when running, denies wheeze or persistent SOB Integumentary:; negative, Head: neg; Eyes: neg ; ENTneg :; Cardiovascular: neg; Respiratory: cough and sob when running in colder/wet weather ; Gastrointestinal:; neg Genitourinary: neg; Musculoskeletal: neg; Neurological: neg Endocrine:; neg Hematologic: neg Psychologic: .neg
SOAP NOTE CASE STUDY WRITING HELP
Objective Data:
Vital Signs: BP; P; R; T; Wt.; Ht.; BMI.
Physical Assessment Findings: (Includes full head to toe review)
HEENT: normocephalic, PERRLA, TMs clear with + light reflex, neg lymphadenopathy, neck with FROM, neg thyroid, carotids 2+, neg supraclavicular nodes.
Lymph Nodes: neg
Carotids: 2+/=
Lungs: CTA with very slight expiratory wheeze
Heart: normal RR/neg m/r/g
Abdomen: so/+bs x 4/ soft and nontender with palpation
Genital/Pelvic: waived
Rectum: waived
Extremities/Pulses: 2+/=
Neurologic: A & O x 3, normal gait
Laboratory and Diagnostic Test Results: Schedule PFT, CXR
Assessment:
- Exercise induced RAD with cough: J45.990
- Asthma: J45.31
- COPD with exacerbation: J44.1
Plan of Care:
PFT’s referral provided
CXR Rx provided
Start inhaled PRN bronchodilator 2 puffs 20 minute before beginning exercise
Consider inhaled steroid with RTC in 2 weeks for follow up review of PFTs, CXR, and med response.
Inhaler use instructions given to patient
Rx for CXR and written instructions for prescriptions provided to patient
RAD education given to patient
RTC at next appointment, to ER with acute exacerbation of SOB and cough
Retrieved from: https://www.aafp.org/pubs/afp/issues/2021/1100/p446.html
(Addressing each dx with diagnostic and therapeutic management as well as education, health maintenance, referrals, and counseling provided).
Reflection: (Reflect on if you agree or disagree with the treatment plan that was made with the preceptor. Also address what if any clinical guidelines were utilized. Support your work with evidence-base literature.)
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