soap note

N503 Acute or Primary Care FNP/Adult 35 yo Male Cough / Cold symptoms

SUBJECTIVE DATA

Chief Complaint (CC): 35 y/o Caucasian male presents to your clinic c/o a cough x 2 weeks

History of Present Illness (HPI): The cough started two weeks ago. I had a cold two weeks ago, but the cough hasn’t gone away. I don’t have any chest pain when coughing, but I have this nagging headache that won’t go away and it’s right above my eyes. I think it’s just a really bad cold that needs some antibiotics. The headache is dull, aching, and heavy. My cough is dry and hacking, like I could cough my socks off. The pain is about a 2-3/10. I’ve been taking Sudafed Cold and drinking lots of fluids. The Sudafed helps for a little while, and I found that steamy showers help a lot, but there are only so many showers one can take in any given day! The headache doesn’t radiate, it just stays above both eyes. My ears feel full, I had a slight sore throat initially, and now it’s just scratchy. My chest is congested, and my head feels like it will fall off when I lean forward to tie my shoes or pick something up off the floor. I notice that I cough more when I first go to bed at night, and really cough hard when I get up in the morning. Then I cough occasionally during the day. Laying down really brings the cough on.

Medications (Meds): Prozac 20mg QD, Cymbalta 40mg QD, Omeprazole 20mg BID, Advil or Tylenol as needed for headache, Sudafed Cold prn

Allergies: No known allergies

Past Medical History (PMH): 10 year history of depression controlled with medication, GERD

Past Surgical History (PSH): Appendectomy in 1996

Hospitalization: No hospitalizations besides for appendectomy

Family History (Fam Hx): Dad is alive at 61 and has history of alcoholism. Mom died at 59 from a stroke. Has one brother 36 who is healthy, a 30 year old sister who is healthy, and a 32 year old sister with bipolar disorder. Has a 2 month old son who is healthy.

Social History (Soc Hx): Smokes 1.5 ppd for 20 years (30 pack year history), drinks about six beers/day, used marijuana in high school but has not used since. No other illicit drug use. Pt is an electrician but is currently unemployed and was laid off 3 months ago

Health Maintenance: Drinks about 7-8 coffees or colas a day. No regular exercise plan.

Review of Systems (ROS):

Constitutional Fever/ chills?

Overall health?

Weight change?

I think I had a fever 2 weeks ago, but none recently

I’ve been feeling overstressed and unhealthy lately

I may have lost a few pounds the last few months

HEENT Ear fullness/pain?

Sore throat?

Nasal congestion?

Nasal dripping?

Swollen glands?

Teeth pain?

My ears do feel full occasionally throughout the day

Initially I had a sore throat, now it’s just scratchy and there’s liquid from my nose dripping down my throat every night

My nose is usually stuffy throughout the day

I’ve been blowing my nose a lot recently with greenish thick snot coming out

I haven’t really checked my glands

No teeth pain

Cardiac Chest pain?

Diaphoresis?

No

No

Respiratory Shortness of breath?

Wheezing?

I get a little short of breath when I climb 2 flights of stairs, I think that’s because I’m out of shape

I’ve not noticed any wheezing.

GI Pain in abdomen?

Nausea

No

No

OBJECTIVE DATA Physical Exam: Vital Signs: Height (Ht): 70”, Weight (Wt): 175 lbs, Temperature (Temp): 99.7, Pulse (HR): 96, Blood pressure (BP): 110/70, RR: 18 General Well developed, well nourished, neatly dressed Caucasian male

in no acute distress