SOAP NOTE

Name:

Mr Dennison.”

Date: 08/25/2020

Time: 1000

 Family Medicine case 02

Age: 40 yo

Sex: male

SUBJECTIVE

CC: 

“Persistent cough for two months.”

HPI: 

Pneumonia, Upper airway cough syndrome, Epiglottitis, Vocal cord dysfunction, obesity or overweight, obstructive sleep apnea, rhinitis or sinusitis, Asthma.

Medications:
cetirizine pills and his inhaled fluticasone nasal inhaler.

PMH

Allergies: None.

Medication Intolerances: None.

Chronic Illnesses/Major traumas – None.

Hospitalizations/Surgeries – None  

Family History 

Social History

gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea, stress, and depression. It appears that Mr. Dennison does have rhinitis or sinusitis which may aggravate his asthma 

ROS

General

persistent cough

Cardiovascular

Denies chest pain or palpitations.

Skin

Denies bruising or rashes. Denies noted lesions.

Respiratory

coughing and whistling noises that you are making at night may be due to asthma.

Eyes

: Normal sclerae and conjunctivae. No discharge or “allergic shiners” are present.

Gastrointestinal

Denies N/V/D, ABD pain, or hemorrhoids.

Ears

 Tympanic membranes are normal.

Genitourinary/Gynecological

Has not had a previous mammogram. Last pap smear was 5 years ago.

Nose/Mouth/Throat

Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present.: Normal appearing; no signs of postnasal drainage.

Musculoskeletal

Denies joint swelling or significant back pain. Denies diagnosis of Osteoporosis.

Breast

Denies breast lumps, discharge, or pain.

Neurological

Denies history of syncope or seizures.

Heme/Lymph/Endo

Denies easy bruising, swollen glands, or intolerance of heat or cold. Admits to occasional hot flashes.

Psychiatric

Denies suicidal ideation or anxiety.

OBJECTIVE

Weight 190lb      BMI 28.9kg/m^2

Temp 98.2

BP 118/68

Height 5’8”

Pulse 80

Resp 16

General Appearance

Healthy appearing male, mildly overweight.

Skin .

No rashes or lesions.

HEENT

Unremarkable. Good dental hygiene, Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage presen. Normal thyroid without evidence of thyroid nodules. Midline trachea.

S1, S2 normal without murmurs or gallops. Pulses equal throughout.

mild scattered wheezes heard throughout

No hepatosplenomegaly, masses, or tenderness.

Symmetric in shape, free of masses and discharge.

Genitourinary

Non-distended bladder. External genitalia without concerns.

Normal ROM throughout. Appropriate muscle development.

Neurological

Cranial nerves intact throughout. Normal sensation, reflexes, and strength. Normal gait.

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests :None
 

Special Tests
: CT scan of the maxillary sinus, it can see ethmoid sinus opacification and maxillary sinus mucosal thickening

 Diagnosis it can see ethmoid sinus opacification and maxillary sinus mucosal thickening.”

 Differential Diagnoses

· 1- Asthma (J45.909)

· 2- Chronic sinusitis (J32.9)

· 3- Cough (R05)

Plan/Therapeutics

· Plan: 

· Medication for Moderate Persistent Asthma

· Antibiotic for chronic sinusitis.

 Evaluation of patient encounter