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Sample SOAP Note: Acute problem

Pam Hiebert

SUBJECTIVE

52 yo male with h/o HTN, hyperlipidemia, COPD. c/o dry, nonproductive cough the past 3 weeks. He coughs frequently during day and night. No exacerbating or alleviating factors. OTC cough syrup not helping. No known exposures. He denies fever, chills, hemoptysis,  chest pain, shortness of breath, wheezing or GERD symptoms. He is up to date on vaccines. He hasn’t smoked for 10 years. Current meds are lisinopril, atorvastatin and albuterol inhaler. Allergic to PCN causing rash.

He also reports his home BP has been high the past few weeks. His home readings are 160/95 average. No headaches or dizziness.

OBJECTIVE

NAD, does not appear ill, Alert. VS T98, BP 150/90, R12, HR 80, 02 sat 98%

Throat clear

Neck no adenopathy

Lungs clear to A and P with an occasional dry cough.

Heart RRR no MRG

Abd benign, non tender.

Ext no edema

ASSESSMENT/PLAN

  1. Chronic cough probably due to lisinopril. Would consider lung cancer in a former smoker. Doubt pneumonia or bacterial bronchitis because he is afebrile and clear lungs. Doubt GERD without reflux symptoms. Doubt COPD exacerbation without wheezing or SOB.

    Will Stop lisinopril. Patient instructed it may take several weeks for the cough to abate. Will order CT lung cancer screening.  Will order benzonanate pills for the cough. Return in one month or sooner if symptoms do not improve or worsen.

  2. Poorly controlled HTN. We are stopping lisinopril due to cough. Will start valsartan 160 mg daily. Will check BMP in 2 weeks. Check BP daily. Return for a nurse visit in 2 weeks to check BP and bring in BP monitor for validation.

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The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.

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