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SOAP Note # Student Name: Course: MSN 651L Today’s date: August 22nd, 2025 ====================================================================================== Demographics: A.A is a 49-year-old white female Visit Date: August 19th,^2025 Clinical Location: Established Pt. SUBJECTIVE: Chief Complaint: “I have been congested for four days and now have a sore throat and cough” Source & Reliability of History: Self-report from patient; patient is a reliable historian. HPI: A.A is a 49-year-old white female here with c/o URI symptoms. Pt states she has been congested for four days now, and her symptoms are worsening. States started yesterday with greenish yellow productive cough, runny nose (clear to yellow in color), fatigue, and sore throat. Pain in throat 5/10 when swallowing on 0/10 pain scale. Denies feeling short of breath unless she has a “coughing spell.” States she is taking OTC medication Mucinex and “other cough medicine” with minimal relief. States she has been “sweaty” but no fever that she is aware of. Does have an old inhaler at home that she has been trying but she is unsure if this has been helpful. States “I think it is expired”- Denies anyone else in the home being sick PMH: Major Depressive Disorder Generalized anxiety disorder GERD Obesity
Exercise Induced Asthma Medications : Escitalopram oxalate (LEXAPRO) 20 mg daily- (SSRI used for anxiety and depression) Hydroxyzine (VISTARIL) 25 mg 3x/day PRN- (Anxiety) Naltrexone-bupropion 8-90 mg 2 tabs twice daily- (Chronic weight management) Albuterol 90 mcg/actuation inhl- 2puffs q 4hrs prn- (asthma) PSH: (Surgical history): Hammer Toe Surgery (left)- 2015 Cholecystectomy (robotic)- 9/18/ Lasik Eye Surgery (bilateral)- 2011 Family History: Mother (living)- HTN Father (living)- No known health issues Brother- No known health issues Sister- No-known health issues No Children Maternal Grandmother (deceased)- Asthma, Breast Cancer Maternal Grandfather- (deceased)- Colo-Rectal Cancer Paternal Grandmother (deceased)- Asthma Paternal Grandfather (deceased)- Unsure of health conditions Social determinants of health: Insurance- UHC- Choice Plus Tobacco: Never Smoker Alcohol: Social- “maybe a few drinks per year” Illicit drug: Never Environmental exposures: None Safety Assessment: Depression Screening PHQ9: 0 Reports feeling safe at home: Yes
Hematologic: Pt denies bruise/bleeding easily Endocrine: Negative for cold intolerance, heat intolerance, polydipsia and polyphagia Musculoskeletal: Pt denies gait problems or muscle weakness Neurologic: Pt denies confusion, dizziness, seizures, syncope, speech difficulty, weakness, light-headedness, tingling or headaches. Psychiatric: Pt denies feelings of depression or anxiety. Pt denies hallucinations, self-injury, sleep disturbance and suicidal ideas. OBJECTIVE: Physical Exam: General appearance: Pt is calm and cooperative with no acute distress. Pt is appropriately dressed. Pt is obese Vital signs: BP 100/62, HR- 98, RR-18, O2- 97% RA, Temp.-97. Height: 5’ Weight: 255lbs BMI: 41. Skin: General: skin is warm and dry, no rash present, no suspicious moles, lesions, or wounds- Coloration: Skin color appropriate for ethnicity.
HEENT:
Head: Normocephalic and atraumatic without tenderness or palpable masses. No scarring noted. Hair is evenly
distributed.
Eyes: PERRLA, Conjunctivae are clear bilaterally without exudate, EOM intact
Right Ear: Auricle well-formed and aligned bilaterally; mastoid process non tender to palpation. No impacted
cerumen. External auditory canal is clear. Tympanic membrane intact, pearly, shiny gray with appropriate light
reflex. No perforation, erythema or drainage noted.
Left Ear: Auricle well-formed and aligned bilaterally; mastoid process non tender to palpation. No impacted
cerumen. External auditory canal is clear. Tympanic membrane intact, pearly, shiny gray with appropriate light
reflex. No perforation, erythema or drainage noted.
Nose: Nasal mucosa erythematous with clear rhinorrhea noted bilaterally. Septum is midline
Mouth/throat: Mucous membranes are pink and moist. Tongue -Negative for lesions and Symmetrical
movement noted. Good dentition noted without odor. Trachea midline
Pharynx: Posterior pharynx mildly erythematous with postnasal drip noted. No tonsillar enlargement or
exudates. No oropharyngeal exudate. Uvula Midline
Neck: Supple- No carotid Bruits, no visible JVD- Thyroid examined from posterior position; gland non-enlarged,
smooth, and mobile with swallowing.
Lymphatics: No Lymphadenopathy palpated on submandibular, submental, occipital, anterior and posterior
cervical chain or supraclavicular-
Thoracic: symmetrical chest rise- No chest wall tenderness
Lungs: Pulmonary effort easy- Clear to auscultation in all lung fields
Heart: Regular rate and rhythm. No murmurs, rubs, or gallops noted. S1 and S2 auscultation clear. PMI at 5th
ICS, midclavicular line, not displaced. No jugular venous distention (JVD). Peripheral pulses 2+ and equal
bilaterally. No edema noted.
Breast: deferred
Abdomen: Abdomen soft and non-tender on palpation. No guarding. Bowel sounds are normoactive x4.
Negative CVAT bilaterally.
Genitourinary/GYN (female): deferred Rectal: Deferred Extremities: Cap refill <3 seconds on fingers and toes, full active ROM x4 extremities, steady without assistive devices, no edema noted x4 extremities. Neurologic: No focal deficit, Alert and Oriented X4. Sensation intact to light touch, 5/5 strength noted in upper and lower extremities, no Gait abnormalities. Psychiatric: Mood and affect appropriate to situation, pt cooperative, appropriate judgement, no evidence of hallucinations- Pt does not appear depressed, anxious, or agitated. Labs and Diagnostic Studies:
related to strep or not have an increase amount of pain in the throat while swallowing. Our patient describes pain in her throat a 5/10 when swallowing. She also reports fatigue which is a common finding. Strep is the most common bacterial cause of this diagnosis and easy to rule out. This patient does not have a fever nor were patchy tonsillar exudates evaluated on exam. The patients point of care strep test obtained in office was also negative, making this diagnosis the least likely. However, again, it is important to rule out as this condition would need to be treated with antibiotics and can worsen if not treated correctly.
Actual diagnosis: Acute Bronchitis - Dx-ICD-10 Code (J20.9)
PLAN:
DIAGNOSIS- Acute Bronchitis Laboratory and Diagnostic Tests: POCT Strep (result listed after exam), POCT Covid/Flu/RSV (result listed after exam) Pharmacology/Medications: _-Start: Rx Prednisone 20mg
Sig: 1 tablet (PO) Once daily No refills -Start: Rx Albuterol sulfate 90 mcg/actuation #1 HHI Sig: Inhale 2 puffs into the lungs every 4 hours as needed No refills_ -Can take Guaifenesin OTC as directed on bottle to help loosen mucous and secretions
- OTC Tylenol as directed on bottle for pain/fever PRN - Can take OTC Dextromethorphan throat lozenges as directed on bag to help control cough impulse (UpToDate, 2025) Non-Pharmacology: Drink plenty of fluids (water) at least 64 ounces per day- Oral Honey with hot team or warm thin liquids- May help soothe throat and reduce cough Cold products- such as sugar free popsicles for throat comfort
Consults / Referrals: N/A Patient education: -Wash hands thoroughly after blowing your nose, eating, using the restroom, etc. -You have been given a steroid dose- It is important to know that oral steroids can cause an upset stomach, increased appetite, mood changes, and trouble sleeping. Please reach out to the provider if you have issues with any of these symptoms. (UpToDate, 2025)
- Make sure you are following the correct directions listed on the label of any OTC medication that you are taking for symptom relief.
- The albuterol inhaler is a quick relief medication. This medication will relax the muscles around the airway. When first using the inhaler, be sure to shake for 5 seconds and spray the first dose into the air to prime the medication. Shake the inhaler for 5 seconds before each use, breathe out a normal breath, close your lips around the canister, press down and breathe in deeply and slowly- Hold your breath for 5-10 seconds if possible. It is important to wait 30 seconds before taking your second puff. (UpToDate, 2025) Patient verbalizes understanding of treatment plan and the above education provided. Follow-up: If your symptoms do not improve or worsen (fever, increased shortness of breath, trouble swallowing), reach out to the office for an appointment. No regular follow-up is necessary as bronchitis should be resolved within 3 weeks. Please plan to follow all education points for an effective healing process ==================================================================================== Health Maintenance Recommendation: Reminder Annual Wellness due 07/03/ Flu Vaccination due 9/1/ Colon Cancer screening due 6/22/2030- Due to family history- screening every five years is advised Breast cancer screening due 7/25/ Cervical cancer screening due 2/21/ Tdap due 8/01/
