SOAP note
Subjective
ID: Dan A. is a 42-year-old Caucasion-Hispanic male who presented with coughing and
wheezing during exercise for the last two months. He is at the clinic alone and is a reliable
source for his health.
CC: “I have trouble breathing while exercising.”
HPI: Dan A. is a 42-year-old male present today at the virtual clinic due to new onset of
symptoms during exercise. Patient developed trouble breathing with dry cough and wheezing
while jogging which started 2 months ago. He usually joggs 5K each day without any difficulties
in the morning or in the afternoon. He runs 5 days a week and 30 mins each time. He reports the
cough and wheezing stops within a minute if he stops his exercise. He will continue running
when symptoms subside. Symptoms get worse when exercise is continued. He reports he is able
to continue with other daily activities without difficulties.
PMH:
Medical problem list: Childhood Asthma
Surgeries and hospitalizations: Appendectomy and MCL tear repair in his mid 20s without
complications.
Immunizations:Up to date. Flu vaccine last October. Received Covid booster.
Allergies: Reports seasonal allergy during March to August. Controlled with Flonase.
Medications: OTC multivitamin.
Family History: Mom is 72-year0old with migraines. Dad died at age of 52 due to emphysema
with a long history of smoking. Maternal grandmother and grandfather died due to old age with
no known medical history. Paternal grandmother died due to old age. Paternal grandfather passed
This study source was downloaded by 100000882699655 from CourseHero.com on 03-18-2024 14:10:02 GMT -05:00
https://www.coursehero.com/file/129087434/MSN-572-Immersion-Sick-SOAPdocx/
Subjective
ID: Dan A. is a 42-year-old Caucasion-Hispanic male who presented with coughing and
wheezing during exercise for the last two months. He is at the clinic alone and is a reliable
source for his health.
CC: “I have trouble breathing while exercising.”
HPI: Dan A. is a 42-year-old male present today at the virtual clinic due to new onset of
symptoms during exercise. Patient developed trouble breathing with dry cough and wheezing
while jogging which started 2 months ago. He usually joggs 5K each day without any difficulties
in the morning or in the afternoon. He runs 5 days a week and 30 mins each time. He reports the
cough and wheezing stops within a minute if he stops his exercise. He will continue running
when symptoms subside. Symptoms get worse when exercise is continued. He reports he is able
to continue with other daily activities without difficulties.
PMH:
Medical problem list: Childhood Asthma
Surgeries and hospitalizations: Appendectomy and MCL tear repair in his mid 20s without
complications.
Immunizations:Up to date. Flu vaccine last October. Received Covid booster.
Allergies: Reports seasonal allergy during March to August. Controlled with Flonase.
Medications: OTC multivitamin.
Family History: Mom is 72-year0old with migraines. Dad died at age of 52 due to emphysema
with a long history of smoking. Maternal grandmother and grandfather died due to old age with
no known medical history. Paternal grandmother died due to old age. Paternal grandfather passed
This study source was downloaded by 100000882699655 from CourseHero.com on 03-18-2024 14:10:02 GMT -05:00
https://www.coursehero.com/file/129087434/MSN-572-Immersion-Sick-SOAPdocx/
