Tpyka-MN552-Unit3-Lab2.docx - 1 Cough SOAP Note Travis Pyka...

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1 Cough SOAP Note Travis Pyka BSN RN Purdue University Global MN552 Advanced Health Assessment & Diagnostic Reasoning Lab 2 November 26, 2020
2 UNIT 3 ASSIGNMENT SOAP NOTE SUBJECTIVE Chief Complaint: Cough for 1 week History of Present Illness (HPI): 45 year old Asian-American female with a PMH of asthma as a child comes to the office with a cough that has been ongoing for 1 week with associated symptoms of shortness of breath (SOB) with wheezing, fever, chills and yellow, green, and pink colored mucus patient states that she is coughing up the pink tinged mucus 3 to 4 times a day. Patient states that the SOB and wheezing are exacerbated with physical exertion such as walking up stairs. Patient denies chest pain at rest or with inspiratio, abdominal pain, weight loss, night sweats, or change in bowel or bladder habits. Allergies: No known allergies (NKA) Past Medical History: Childhood Asthma Family History: Patient denies knowledge of other illnesses in her family.

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