SOAP Notes (Coursework Sample)

A Soap Note HEENT Student Name Institution Course Tutor Date A Soap Note HEENT Patient Information: Name: T.J. Age: 50 Sex: Female SUBJECTIVE Chief Complainant: "I have been experiencing breathing difficulties since yesterday." Patient history: T.J. is a 50 years old Caucasian female who arrives at the clinic complaining that she experiences breathing difficulties. The patient reports a dry cough, shortness of breath, nausea, unceasing fatigue, and loss of taste, smell, and appetite. Presently, the client reports working at the airport where different people converge for their travels. More so, for the past 1 day, she reported experiencing running nose, clear mucus, and congestion. Current Medication: The patient is using quick pain relief medication, Ibuprofen 400mg, and a short–acting beta2-agonists, which are used to relieve sudden asthma symptoms such as difficulty in breathing. Allergies: no known allergies PMHx: None Family History: Both parents are alive. The father has hypertension, the mother has diabetes, the brother is overweight, and the sister is asthmatic. Also, her paternal mother and father have diabetes. Social History: The patient denies smoking but takes four cans of alcohol weekly. Also, the patient indicates that he has no pet that would trigger an asthmatic environment and lives and works in a clean and disinfected place. REVIEW OF SYSTEMS HEENT:  The patient denies sore throat and changes in hearing. However, she indicates that she has experienced some pain while swallowing food items. SKIN:  The patient's skin is warm to the touch, turgor normal, no brittle hair, no rashes or itchiness. However, she experiences sweating. EYES: The patient does not give any vision impairment problem EARS: The patient denies having experienced hearing loss. CARDIOVASCULAR:   The patient has a burning sensation on her chest when lying. RESPIRATORY: The patient experiences shortness of breath and some dry cough. Also, she experiences a running nose. GASTROINTESTINAL: The patient denies vomiting and diarrhea. However, she experiences waves of nausea, loss of taste and appetite. GENITOURINARY:  The patient denies vaginal discharge and denies hematuria. NEUROLOGICAL:  The patient denies loss of sensation. MUSCULOSKELETAL: The patient denies fainting, joint swelling, and dizziness. HEMATOLOGIC:  The patient does not have bruising or anemia. LYMPHATICS:  The patient has no enlarged nodes. PSYCHOLOGICAL: The patient denies experiencing suicidal intentions or depression. OBJECTIVE Physical Exam: The patient's height is 6′ 2″, weight 74.7kg, pulse 27, and temperature 99.9F. General: The patient is cooperative, awake, has a clear speech, attentive, and pleasant. Also, she maintains eye contact. HEENT: The patient has no swelling, sinus pain while bending, no exudate, + clear post-nasal draining. NECK: The patient's thyroid is smooth. CHEST/ LUNGS: The patient does not experience wheezing. Heart: The patient has a regular rhythm and no murmurs. Musculoskeletal: The patient has no swelling, and she experiences a normal motion range. Nuero: alert and oriented. Skin/ lymph nodes: no cervical lymphadenopathy Diagnostic results: The patient was suffering from SARS-COVID-19. This is because she was facing severe difficulty breathing, convoyed with unceasing fatigue, and loss of taste, smell, and appetite. These symptoms match those revealed by Vihta et al. (2021), which state that SARS-COVID-19 symptoms are cough, loss of taste/smell, and fever. Laboratory studies: SARS-COVID-19 ICD-10 Z11.07.1 & Z20.16 CPT 99314, 87765, 87814 Chemistry Panel: Glucose: 116 POC testing Pylori serology: negative Differential Diagnosis: SARS-COVID-19: corona disease is an infectious condition caused by the SARS-CoV-2 virus (Ortiz-Prado et al., 2020). The common symptoms of the disease include loss of taste and smell, tiredness, shortness of breath, and chest pain. Rationally, T.J. is likely to suffer from SARS-COVID-19 due to a close diagnostic criterion selected. According to the patient's symptomology aspect, she reports t to have a loss in taste and smell sense, thus indicating high chances of COVID-19. Respiratory Syncytial Virus: RSV is a respiratory virus characterized by cold-like symptoms (Kurai et al., 2020). The condition is spread through droplets from the infected patient nose and throat. Due to close symptom similarity, the condition is the second in the differential diagnosis due to inadequate physical signs and a -ve POC testing. Seasonal Influenza Virus is a common preventable condition caused by the influenza virus, mainly characterized by respiratory symptoms. Influenza types A and B have similar symptoms, by the patient tested a -ve POC testing. ASSESSMENT AND PLAN: Labs and Diagnostic tests to be ordered: According to T.J.'s condition, the lab test work was minimal, and I chose to conduct POC testing. Here, the symptoms revealed SARS-COVID-19 due to loss of smell senses and smell. Still, the condition does not require an x-ray or further lab work. This is so since there has been a decrease in such patients with COVID-19 symptoms, thus lowering higher numbers of hospitalization. Also, since the patient is likely to suffer from SARS-COVID-19, it will be essential to plan on initiating self-isolation to the patient to monitor her symptoms. This will be important in preventing the patient from transmitting the disease to other individuals. Pharmacological treatment: The patient will be treated using monoclonal antibodies and antiviral medication known to treat individuals infected by COVID-19 (Jaworski, 2021). Here, the antiviral treatment invades specific parts of the virus, thus limiting ...