SOAP 3.1)-1.docx - SOAP NOTE ASSIGNMENT 3.1 Basic...

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SOAP NOTE: ASSIGNMENT 3.1Basic Information55-year-old maleSubjective HistoryChief Complaint“sinus pressure, sore throat, headache, productive cough”History of Present IllnessA 55-year-old male presents with six days of sinus congestion and pressure, sore throat, headache, and a productive cough that is worse at night. He is currently taking care of his wife who is undergoing chemotherapy for advanced breast cancer. Patient denies any exposure to other ill individuals. Patient states he does not get the flu shot. Patient endorses seasonal allergies. Patient states chest soreness from "coughing." Patient denies any other complaints, symptoms, or concerns. Patient endorses having pneumonia vaccine a couple of years ago. Past Medical HistoryPt is up to date with immunizations, no recent hospitalizations or surgeries, appendectomy in 2008. Denies history of recent illness or exposure, trauma, positive for seasonal allergies. Taking Multivitamin daily. Taking Allegra Allergy 180 MG Tablet 1 tablet as needed Orally Once a day
Family HistoryMother alive with diabetes, Father alive with hypertension. No family history of seasonalallergies.Personal/Social HistoryPatient obtained Bachelor of Engineering, Married, Works at Ford Motor company, no alcohol or drug use, does not smoke, never smoker, sexually active, does not exercise, does not attend church, eats vegan dietReview of Systems (as applicable to CC)General: Positive for fever and fatigue. Denies chills or weight lossHair, Skin, & Nails: Negative for changes in hair, skin, or nails. Negative for rash or pruritus.

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