MN 552 - SOAP NOTE-FINAL 2023 latest

MMC is a 56 -year- old, African American female who presented to the health assessment this morning with concern about a cough. She stated her name as Mrs. MMC, she is alert and oriented times 4. She can tell time of day, where she currently is, and she is cooperative with all assessments. Patient is English speaking and explains her current concerns clearly. She reports having concerns with a cough and that she fears the cough is getting worst. Otherwise, Patient verbalized being in general good health. There were no signs of distress throughout the visit, her attire, behavior and body language were appropriate. Chief Complaint Patient States, “I have this cough that won’t go away, and I am worried about it”. She reported that the cough has gotten worst over the past 2 weeks as it is more frequent and last longer with each episode. History of Present Illness Mrs. MMC reports that she the coughing started about a about a month ago. She states that it gets worst at nights, and usually comes on while she is laying down to sleep or wakes her out of her sleep. She states the cough sometimes happens when the overhead fan in the bedroom 3 Running head: UNIT 4: Comprehensive SOAP Note and Genogram is on. She denies cough with activity, and denies any incidents of vomiting with the cough. The cough usually don’t last more than a minute. She reports having mucous plug in the mornings upon awakening, and must cough to clear her throat. She states that her chest feels tight, especially on the right side, but is relieved after clearing with a good set of coughs. She describes the cough as dry most times, or at times she may expectorate a scan amount of clear thin sputum. she does state that in the mornings her mucous is thicker. The cough is irritating to her throat but is usually relieved with a sip or two of water when the cough occurs. She reports that she also taking Robitussin DM (