Ihuman Case Study SOAP notes help to provide a brief on the analysis and diagnosis of the patient. M.W. has a chief complaint of coughing regularly. In regard to his interview, this has gone on for four days.
Below is the SOAP Note of M.W. Diagnosis
Patient: M.W
CC: “I am coughing all the time”
ID: M.W. is an 18-year-old college student who is a reliable historian.
HPI: M.W. presents with a cough that started suddenly four days ago. He reports that the cough is associated with fever tmax 104, shaking chills, shortness of breath, pleuritic chest pain with deep inspiration, fatigue and myalgia also starting four days ago. MW describes the cough as severe and persistent, awaking him from sleep. He reports the cough as originating from his chest and productive with thick, yellow to green-colored sputum. He states that drinking hot tea initially alleviated his cough, but is no longer working. He also tried using his inhaler to alleviate the cough without relief.
PMHx: M.W. reports a recent flu illness which seemed to have resolved. He also reports childhood asthma, but is no longer on therapy and has not had any recent attacks. No other medical/surgical history per patient.
FMHx: Unremarkable
Social Hx: MW is a college student and reports that he started feeling sick while at a party. He states he is typically active and is a “ball player”. He denies smoking, tobacco or recreational drug use. He states he has an occasional beer or glass of wine after studying.
Current medications: Ibuprofen, two tablets every four hours as needed. Allergies: No known allergies
ROS
General: Reports fatigue, myalgia and shaking chills. Denies weight loss or night sweats.
HEENT: denies sore throat but reports “scratchy throat” after coughing. Denies headaches. Denies sinus or ear pain. Reports swollen lymph nodes to neck.
Respiratory: Denies wheezing. Denies hemoptysis.
Cardiovascular: Denies palpitations. Denies chest pressure or tightness. Reports7 or 8/10 right sided chest pain after coughing or deep inhalation. Denies chest pain that radiates.
Gastrointestinal: Denies coffee colored vomit. Denies vomiting, diarrhea, constipation or bloody stools.
Musculoskeletal: Denies joint swelling or redness, back pain, neck, shoulder or hip pain. Skin: Denies rashes or lesions.
Genitourinary: Denies dysuria, urinary frequency or burning.
Physical exam/Objective:
Vital Signs: T 103.2 F (febrile), HR 120 bpm (tachycardic), RR 24 breaths per minute and regular (tachypneic), BP (supine) 120/80,BP (upon standing)102/80, SpO2 91% RA (hypoxic)
Skin: Tenting of the dorsal aspect of hand. No rashes or lesions. Cap refill is normal.
Neuro: Cranial nerves I – XII are intact. Pt is alert and oriented. Deep tendon reflexes are 2+.
HEENT: dry mucous membranes of mouth. Tonsils slightly enlarged and red. No abscess or airway compromise. Tympanic membranes normal. No polyps or dischargenoted from nares. Eyes are without discharge.
Neck: Tender 1.0 – 1.5 cm anterior cervical lymph nodes. No accessory muscle use of neck with respirations.
Respiratory: Right middle lobe and right lower lobe lung fields noted with coarse crackles upon auscultation. Productive cough noted. Pt is tachypneic. ABG blood test result with hypoxia (PaO2 60 and SpO2 91%). Lung fields resonant on percussion, no hyper resonance. Chest Xray demonstrates right lobe infiltrate.
Chest: Excursion is normal. AP diameter normal. Chest is symmetrical. No retractions or accessory muscle use noted. No masses or rashes.
Musculoskeletal: Normal muscle bulk and tone. No swelling, cyanosis or deformities of extremities and joints. Muscle strength is 5/5 bilaterally.
Genitourinary: No urethral discharge or masses. External inspection is normal.
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