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
D. Medications
E. Allergies
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
III. Assessment (A)
Likely a viral upper respiratory infection (URI).
Fatigue related to viral illness or sedentary lifestyle.
Hypertension is controlled.
IV. Plan (P)
A. Medications
B. Diagnostics
C. Patient Education
D. Follow-Up
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