Cough Internal Medicine SOAP Note Transcription Sample Report

REASON FOR VISIT: Cough, headache, nasal congestion and chest congestion.

SUBJECTIVE: The patient is (XX)-year-old female with complaint of headache, facial pressure and nasal congestion with a yellow-greenish nasal discharge, mild sore throat, dry cough, chest congestion, episodes of chills and sweating, a sensation of fever. The patient has been sick for five days. The patient denies at the present time fever, nausea, vomiting, abdominal pain, constipation or diarrhea. The patient is a chronic smoker. The patient usually smokes half a pack a day for 15 years. The patient is not allergic to any medication.

OBJECTIVE: Vital Signs: Blood pressure 98/68, pulse 66, temperature 98.4. The patient is well developed, well nourished, in no acute distress. Skin: Warm, dry, no bruises and no rashes. Oropharynx: Normal. Nose: Mucosa swelling, red, no ulceration, tender maxillary and frontal sinuses. HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Neck supple. No lymphadenopathy. Lungs: Clear. Heart: Normal S1 and S2, regular rhythm. Abdomen: Benign exam. Extremities: No edema, cyanosis, deformities.

ASSESSMENT AND PLAN: Acute rhinosinusitis. We recommended starting Z-Pak, take as directed. Robafen With Codeine syrup, 1 teaspoon 3 to 4 times a day. We warned the patient that Robafen contains codeine and may cause drowsiness and to be careful when driving. Flonase nasal spray one spray twice a day. Combivent inhaler 1 puff 3 or 4 times a day. Motrin 400 mg 3 times a day as needed. We discussed with the patient cessation of smoking.

Sample #2

REASON FOR VISIT: Cough.

SUBJECTIVE: The patient is a (XX)-year-old female who has complaint of cough, dry, with scanty phlegm, episodes of wheezing and shortness of breath on exertion. The patient had a cold/flu two weeks ago. The patient has been treated with Z-Pak, and the patient has had improvement, but since then, the patient has had constant dry cough with episodes of wheezing and shortness of breath. The patient denies any fever, nausea, vomiting, abdominal pain, constipation or diarrhea. The patient denies headache, chills and wheezing.

OBJECTIVE: Vital Signs: Blood pressure 114/82, heart rate 70 and temperature 97.8. General: The patient is well developed, well nourished, not in acute distress. Skin: Warm, dry, no bruises and no rashes. HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Neck supple. No lymphadenopathy. Lungs: Chest symmetry with respiration. No wheezing or crackles. Heart: Normal S1 and S2, regular rhythm. Abdomen: Benign exam. Extremities: No edema, cyanosis, deformities.

ASSESSMENT AND PLAN: Postinfectious cough: We recommend the patient start Robafen With Codeine syrup 1 teaspoon 3 to 4 times a day. We warned the patient that Robafen contains codeine and may cause drowsiness and to be careful when driving. Flovent inhaler 110 mcg 2 puffs twice a day, ProAir inhaler 1 to 2 puffs every 4 to 6 hours as needed.

Sample #3

REASON FOR VISIT: Sore throat, headache, chest congestion and cough.

SUBJECTIVE: The patient is a (XX)-year-old male who complains of a dry cough with scanty phlegm coming up and chest congestion, headache, nasal congestion with a yellow-greenish discharge, facial pressure and mild sore throat. He had episodes of the chills and sweating. The patient has been sick for three days. The patient denies nausea or vomiting, abdominal pain, constipation, diarrhea and fever. The patient denies history of smoking. The patient does not have any allergies to any medication.

OBJECTIVE: Vital Signs: Blood pressure 106/78, heart rate 80, temperature 98.2.General: The patient is well developed, well nourished, and not in acute distress. Skin: Warm, dry, no bruises and no rashes. Oropharynx: Normal. Nose: Mucosa swelling, red, no ulceration. Mild tenderness of the frontal and maxillary sinuses. HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Neck supple. No lymphadenopathy. Lungs: Clear. Heart: Normal S1, S2, regular rhythm. Abdomen: Benign exam. Extremities: No edema, cyanosis or deformities.

ASSESSMENT AND PLAN: Acute rhinosinusitis. We recommended starting Z-Pak and to take as directed. Flonase nasal spray one spray twice a day. Robafen With Codeine syrup 1 teaspoon 3 to 4 times a day. Robafen contains codeine, which may cause drowsiness. We warned the patient to be careful when driving. Hydration. Motrin 400 mg 3 times a day as needed.