NURS 623 SOAP note adult 2 pneumonia and PE.
S.O.A.P. Note
Chief Complaint
Shortness of breath and still not feeling well
History of Present Illness
A 72-year-old male presents to with shortness of breath while at rest and that it gets worse with
movement. Pt complains of “not feeling well” even after taking all of his azithromycin last week.
Patient reports a productive cough. Patient complains of pain in lungs with coughing. Pain is at a
4/10. Patient was on azithromycin and finished dosing yesterday and thought he hasn’t really felt
any better since starting the antibiotic.
Past Medical History
Past Medical history: hypertension
Past surgical history: Left Hip replacement in 2012
Patient is current in his immunizations
No Medication or seasonal allergies
Current medications include Lisinopril 10mg PO QD.
Family History
Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent
medical illnesses
Mother: Asthma, hypertension and type 2 diabetes Died at 92 of natural causes
Father: Hypertension died at 82 of CVA
Brother: Asthma, type 2 Diabetes
Personal/Social History
Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if
relevant, exercise, nutrition, religious preference if known
Patient has a Bachelors degree in Accounting and is retired. Patient is widowed and has son and
daughter that help take care of him. Pt denies any alcohol or illicit drug use. He does not smoke
or use chewing tobacco. Pt does not moderate exercise and is on a regular diet.
Review of Systems (as applicable to CC)
General: Positive for fever and fatigue. Negative for chills, lethargy, and night sweats
Hair, Skin, & Nails: Negative for rashes or lesions. Negative for nail changes. Negative
for hair loss.
S.O.A.P. Note
Chief Complaint
Shortness of breath and still not feeling well
History of Present Illness
A 72-year-old male presents to with shortness of breath while at rest and that it gets worse with
movement. Pt complains of “not feeling well” even after taking all of his azithromycin last week.
Patient reports a productive cough. Patient complains of pain in lungs with coughing. Pain is at a
4/10. Patient was on azithromycin and finished dosing yesterday and thought he hasn’t really felt
any better since starting the antibiotic.
Past Medical History
Past Medical history: hypertension
Past surgical history: Left Hip replacement in 2012
Patient is current in his immunizations
No Medication or seasonal allergies
Current medications include Lisinopril 10mg PO QD.
Family History
Include parents, siblings; grandparents if applicable/known, cause of death, age, pertinent
medical illnesses
Mother: Asthma, hypertension and type 2 diabetes Died at 92 of natural causes
Father: Hypertension died at 82 of CVA
Brother: Asthma, type 2 Diabetes
Personal/Social History
Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if
relevant, exercise, nutrition, religious preference if known
Patient has a Bachelors degree in Accounting and is retired. Patient is widowed and has son and
daughter that help take care of him. Pt denies any alcohol or illicit drug use. He does not smoke
or use chewing tobacco. Pt does not moderate exercise and is on a regular diet.
Review of Systems (as applicable to CC)
General: Positive for fever and fatigue. Negative for chills, lethargy, and night sweats
Hair, Skin, & Nails: Negative for rashes or lesions. Negative for nail changes. Negative
for hair loss.
