Free Family Practice Soap Note

Prepared by: [Your Name]

I. Subjective (S)

A. Chief Complaint

The patient reports experiencing a persistent cough and fatigue for the past 7 days.

B. History of Present Illness

The patient, a 45-year-old male, states that the cough is non-productive and worse at night. He rates his fatigue level as 7/10 and reports difficulty performing daily tasks. He denies fever, chills, or shortness of breath.

C. Past Medical History

• Hypertension is controlled with medication (Lisinopril 10 mg daily).

• Seasonal allergies.

D. Medications

• Lisinopril 10 mg daily.

• Loratadine 10 mg as needed for allergies.

E. Allergies

• Penicillin (rash).

F. Social History

• Non-smoker, no alcohol use.

• Works as an accountant with, a sedentary lifestyle.

G. Family History

• Father: Hypertension.

• Mother: Diabetes type 2.

II. Objective (O)

A. Vital Signs

• Blood Pressure: 128/84 mmHg.

• Heart Rate: 78 bpm.

• Respiratory Rate: 18 breaths/min.

• Temperature: 98.6°F.

• Oxygen Saturation: 97% on room air.

B. Physical Examination

• General Appearance: Alert and oriented, appears slightly tired.

• HEENT: No nasal discharge, throat mildly erythematous without exudates.

• Lungs: Clear to auscultation bilaterally, no wheezes or crackles.

• Cardiovascular: Regular rhythm, no murmurs.

• Abdomen: Soft, non-tender, no masses.

• Extremities: No edema.

C. Diagnostic Results

• Rapid COVID-19 test: Negative.

• Chest X-ray: Pending.

III. Assessment (A)

1. Likely a viral upper respiratory infection (URI).

2. Fatigue related to viral illness or sedentary lifestyle.

3. Hypertension is controlled.

IV. Plan (P)

A. Medications

• Prescribed guaifenesin 200 mg twice daily for symptomatic relief.

• Advised to continue Lisinopril and Loratadine as directed.

B. Diagnostics

• Awaiting chest X-ray results.

C. Patient Education

• Encouraged increased fluid intake and rest.

• Discussed the importance of physical activity and considering a mild exercise routine once symptoms resolve.

D. Follow-Up

• Return in 7 days or sooner if symptoms worsen or new symptoms develop.

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