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SOAP Note Example

Date: 04-10-07

Patient Name: James Harrington

Chief Complaint: Mr Harrington is back


for follow up having had a recent
hospitalization for treatment of
pneumonia.
SUBJECTIVE:
On 3-15 he developed fever and went to ER on 3-17 where CXR revealed
pneumonia. He had had a one week history of fatigue and shortness of
breath. Prior to this no gasping, but did have a productive cough which was
clear sputum without any blood. He was hospitalized and admitted into the
ICU and given intravenous antibiotics and pulmonary consultation was
undertaken. He states that he had cut his smoking approximately 50% prior
to this episode – down to approx. ½ pack per day. CXR and CT scan
showed a right upper lobe infiltrate with no masses and mild hilar
prominence without any adenopathy and diffuse COPD on the x-ray report
dated 4/11. On 4/20, he had another CXR that there is no report for; but by
his statement was reported as improved. He was given 2 different
antibiotics and then a 3rd antibiotic for his GI tract. He was on Advair and
breathing treatments at home following discharge.

He has had no cardiac symptoms as angina, PND, or orthopnea and he had no


other symptomatology in neuro, renal, or GI areas. He did have a history of
hematuria and has been seen by urologist for that and will be seen later this
week for F/U.

Past medical history is unchanged from that previously noted. He did stop
taking his Lisinopril independently without recommendation from the
physician. His remaining past medical history, family history, social history,
a view of systems is unchanged from prior exams except as noted above.
OBJECTIVE:
Physical Examination:
Vital Signs: Pulse – 84 and regular, Respirations – 20, Blood Pressure –
145/80 (RUE), Weight – 170 to 175 lbs. (by patient’s report).
HEENT: unremarkable with no oral lesions, no abnormalities with his eyes or
ears.
Neck: supple without JVD or bruits, there is no adenopathy either in his jugular
chain bilaterally or the supraclavicular or infraclavicular areas bilaterally.
Chest and Pulmonary: clear with no rales or rhonchi, no wheezing or rubs;
decreased breath sounds diffusely as noted previously.
Heart: Heart sounds are normal with grade 3-4/6, holosystolic murmur at lower
left sternum border radiating to apex and axilla. There is no gallop, rub,
heave or lift.
Abdomen: Unremarkable with no masses, tenderness or organomegaly. His
abdominal pulsation in the midline seems to be slightly more prominent then
it was 2 months prior, but no discreet aneurysm is present.
Rectal: deferred
GU: deferred
Extremities: Full range of motion with pulses unchanged being 4+ in the upper
extremities, 4+ femoral, popliteal and 4+ pedal pulses except for his right
dorsalis which is 0 - 1.
Neuro: grossly intact, with no focal signs; cranial nerves intact.
ASSESSMENT:
COPD with recent episode of pneumonia – needs F/U CXR, possible CT
Scan, possible Bronchoscopy
1) Mitral Regurgitation (more prominent MR murmur) – needs F/U echo
2) CAD – may need F/U stress thallium / stress echo
3) Hematuria – F/U by local and NY urologists
4) AAA – needs Abdominal U/S
5) C. Diff Enteritis – currently inactive

PLAN:
Mr. Harrington is to return to New York within the next 2-3 weeks.
He is to be seen by his local physician for follow up for a number of these
issues and these were discussed in detail with him. He is to see his
local urologist later this week.
Specifically: COPD with pneumonia (R/O CA), Mitral Regurgitation, CAD,
Hematuria, C. diff. enteritis, Possible AAA

He is to have a colonoscopy at some point during the summer.


He will be seen in F/U on his return to Florida in the fall.

(signed) William G. Marshall, Jr; MD