SOAP Note and Genogram Mrs. M

SOAPNote and Genogram

&nbsp Mrs. M

5/9/16

Time: 1235

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Age:55

Sex:Female

SUBJECTIVE

CC:&nbsp I have a persistent cough and I need treatment

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HPI:&nbsp&nbspMrs. M is a 55-year-old woman who presents to the hospital with a 12-day history of a cough. She reports that it started as a chest cold, but has failed to get better. She also reports that the cough is productive, with clear sputum. It is worse at night when she is lying down. She has tried anti-cough syrups but says no change. She also reports of chest tightness and some wheezing. She has experienced a low-grade fever with no chills. She denies paroxysmal nocturnal dyspnea, with easy fatigability. No history of hemoptysis. She also has a history of smoking.

Medications:

She is a known type 2 diabetic on metformin, 500mg BID.&nbsp

PMH

No known food or drug allergies

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No medication Intolerances

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Chronic Illnesses/Major Traumas-Diabetes type 2

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Hospitalizations/Surgeries-none

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Family History

Father (Alive)- Diabetes and hypertension

Mother (Alive) – hypertension

Brother (45 years)- hypertension

Daughter (33years)- diabetic

Son- healthy (27 years), no health care complications

Social History

Mrs. M is a retired math teacher. She is now the chair of teachers’ association and stays with her husband and two children. She is a chronic cigarette smoker and has been smoking since she was 20.&nbsp

ROS

General

She reports to be in a fair general condition with no chills and fever.

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Cardiovascular

She denies any history of rheumatic fever, heart murmurs, irregular beat, or palpitations.

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Skin

No rashes, bruising, bleeding, skin discolorations, or changes in moles.

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Respiratory

Reports cough, wheezing, and shortness of breath with chest tightness.

Eyes

She denies the use of lenses and says that her sight is normal.

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Gastrointestinal

She does not report of any abdominal pain, constipation, eating disorders. No nausea and no vomiting.

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Ears

Mrs. M denies ear pain, hearing loss, ringing in ears, or discharge.

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Genitourinary/Gynecological

She reports no change in the color of urine, urgency, or frequency.&nbsp

Nose/Mouth/Throat

Nothing significant to report

Musculoskeletal

No history of fractures, back pain, joint pain, or stiffness.

Breast

No tenderness, no masses and no dimpling on either breast.

Neurological

She denies any head injuries, no syncope, and seizures.

Heme/Lymph/Endo

She does not report any swollen lymph nodes.

Psychiatric

She denies any episodes of depression, anxiety, insomnia, suicidal ideation/attempts.

OBJECTIVE

Weight: 160lbs&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp BMI29.2

Temp99.8

BP110/70

Height: 61 inches

Pulse92

Respiratory 28

General Appearance

Mrs. M is in a fair general condition, but looks tired and has labored breathing. She is oriented to person, place, and time and answers questions appropriately.

Skin

There are no signs of bruising, swelling, rashes or lesions noted. The skin is clean, warm, dry, and intact.

Eyes- The right conjunctiva and sclera is clear. Red reflex present. Visual Acuity: 6/6

Ears- the auditory canals are patent, no excessive cerumen noted. Tympanic membranes are visualized bilaterally and are pearly gray. No bulging noted, no erythema, or fluid noted behind the TM.

Nose- septum is midline, nasal mucosa is pink, no perforations, or polyps noted.

Neck- there is a full range of motion, no lymphadenopathy present, and trachea is midline, and the thyroid non-palpable.

Oral mucosa- no lesion present, dentition is good.

No lymph nodes palpable in cervical, axillary, or epitrochlear.

Cardiovascular

JVP-6cm. S1 &amp S2 are clear with regular rate and rhythm. No added heart sound. No edema or discoloration noted. Capillary refill &lt 2 seconds. No rubs, clicks, or murmurs noted.

Respiratory

Bilateral diffuse wheezes are heard with expiration. No crackles auscultated. Respiratory rate-28 breaths per minute.

Gastrointestinal

On inspection, the abdomen is non-distended with no obvious marks or distended veins. On palpation, no masses are felt. Four bowel sounds are auscultated per minute. No organomegally noted.

Breast

Breasts non-tender with no masses palpated.

Genitourinary

Permission denied by patient.

Musculoskeletal

Full range of movement on the four extremeties.

Neurological

Awake and alert. No confusion noted.

Psychiatric

good eye contact maintained and articulates with positive affect.

Lab Tests

Full hemogram-bacterial pneumonia ruled out

Special Tests- sputum for culture and sensitivity

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&nbspASSESSMENT FINDINGS AND PLAN

    • Diagnosis

    • Acute bronchitis

    • Bacterial pneumonia

    • Asthma

    • Final Diagnosis: Bronchitis

    • Plan:&nbsp

      • No further testing needed

      • Manage with albuterol inhaler, two puffs QID

      • Education- Instruct her how to use the inhaler and warn her of the effects of smoking.

      • Non-medication treatments- Encourage hydration. Eat regular meals. Avoid triggers identified in headache diary.

      • Follow-up the next day, and if symptoms get worse, consult a senior physician.

Genogram

78 71 8590

Paternal father

Maternal mother

85

85

Maternal father

Paternal mother

Child

Child

DM and HTN Hypertension Hypertension Healthy

45 58 63

Mr. M

Mrs. M

Brother

Deression Diabetes Healthy Hypertension

33 27

DiabetesHealthy

Legend

Female Male