Mr week 3 soap
*Subjective:
CC:
HPI: Mrs B is a 64 y/o Caucasian female patient that presents with a cough over the last 4 weeks
that is moderate in severity. She initially presented to the walk-in clinic last week and was
diagnosed with an upper respiratory infection and was prescribed azithromycin. Mrs. B feels that
the antibiotic was not helpful and she has not been sleeping well due to the congestion and
cough. She denies nasal discharge but is coughing up clear/white phlem. She reports feeling like
she cannot get the mucous out of her chest and feels SOB at times. She denies any body aches,
fever, chills, chest pain or poor oral intake.
PMH: PMH includes
Osteopenia (2019), Depressive disorder (1980), hypertension (2016), COPD (2016),
hyperlipidemia (2018), type II DM (2018), morbid obesity (2018), Hospitalized (9/2018) for 7
days with pneumonia,
Surgery history: Left femur fracture (2018), Hysterectomy- age 45, Appendectomy- age 30,
Colonoscopy (2015), Coronary Artery Bypass (CABG) – x5 (2016), Dilation & curettage,
Hemorrhoidectomy (2012), Tubal ligation- age 35
Allergies: Keflex- angioedema, Metformin- diarrhea, Quinine- angioedema, Ultram-
angioedema
Medications:
albuterol sulfate HFA 90 mcg/actuation aerosol inhaler. Inhale 2 puff(s) every 4 hours by
inhalation route.
benzonatate 200 mg po TID PRN
Breo Ellipta 100 mcg-25 mcg/dose powder 1 inhalation every day
Duloxetine 20mg po daily
Finofibrate 160mg po daily
glipiZIDE ER 10 mg tablet po daily
HCTZ 25mg po daily
Rosuvastatin 10mg po daily
Lisinopril 10mg po daily
Metoprolol tartate 25 mg po daily
Social History: Mrs. B is a retired factory worker and has lived in Florida for 3 years. She
currently smokes ½ pack of cigarettes for 20 years. Drinks 1-2 beers per week. She is widowed
since 2002 husband passed from complications of Emphysema. She has two adult daughters
living at home. Her grandchildren live with their father who has sole custody. Mrs. B owns a
home which is paid for. Daughter Brenda has two jobs. Her son in law also lives in the home he
works. All family members smoke in the house. She has four dogs, 10 outdoor cats, and 5 birds
living in the garage.
Family History: Father died of MI age 60
Mother- colon cancer and died at age 70
Health Maintenance/Promotion: Up to date on immunizations, flu (10/2018), pneumonia
(1/2018 & 11/18). Colonoscopy and Mammogram up to date (12/2018). Diet- Diabetic. She
occasionally exercises by walking.
ROS:
General: Feeling tired, usual weight, and below her baseline of health.
Skin: Denies skin or hair changes
HEENT: Denies headache or injury. Denies vision changes, redness, earaches, or hearing
changes. Denies nasal discharge. Sore throat at times from coughing. No muscle aches, itching or
sinus trouble.
Respiratory: Productive cough with phlegm that is white/clear. C/o SOB. Last CXR 2019
Cardiovascular: Denies chest pain, dyspnea, orthopnea, or palpitations. Denies rheumatic fever,
heart murmur. Pertinent for hypertension. Last BP taken this visit.
*Objective:
PE:
Gen: Well developed female in no apparent distress. She is cooperative and pleasant. Hair is
well groomed.
VS: BP 126/78 HR 76 O2 sat 96% on RA RR 20 T 97.9 Height 60 inches Weight 178 LBs BMI
34.8
/Skin: Dry, intact. No rashes or erythema noted.
HEENT: Head without lesions. Hair texture average. Conjunctiva clear without discharge. Ear
canals clear, tympanic membrane pearly grey without redness. Hearing grossly intact. Nose
without external lesions and mucosa not inflamed. Throat and oral pharynx with mild erythema.
Dentures in place, well-fitting without tenderness or abscess noted. No exudate or lesions. No
Frontal and maxillary sinus tender to palpation. No lymphadenopathy.
Lungs: Chest wall expansion shallow but symmetrical. No use of accessory muscles or SOB
noted. Lung sounds with wheezing and rhonchi throughout.
CV: Chest symmetrical. Rate regular. Normal S1 and S2. No carotid bruit. No JVD. No digital
clubbing noted. No cyanosis. No murmurs noted.
Diagnostic Tests: Chest X-ray- mild chronic bronchitis
