History of Present Illness (HPI)
Chief Complaint (CC) “Breathing problems” CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - for instance
"headache", NOT "bad headache for 3
days”. Sometimes a patient has more
than one complaint. For example: I...
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: TJ Age: 28 Gender: Female
Height Weight BP HR RR Temp SPO2 Pain Allergies
170cm 89kg 140/ 89 20 98.5 97% Medication: Penicilllin- rash/hives; as a child
81 Food: NKFA
Environment: Cats and dust- itchy watery eyes,runny nose, exacerbates
asthma
History of Present Illness (HPI)
Chief Complaint (CC) “Breathing problems” CC is a BRIEF statement identifying
Onset Diagnosed with asthma at age 2 and ½ years; exacerbation two days ago why the patient is here - in the
Location Chest and lungs patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Two days ago. Episodes occurring approximately every 4 hours or “5 times a
days”. Sometimes a patient has more
day”
than one complaint. For example: If
Characteristics SOB not well relieved by inhaler, DOE, wheezing, difficulty breathing while the patient presents with cough and
lying flat, dry cough, waking at night due to SOB sore throat, identify which is the CC
Aggravating Factors Expsosure to cats and dust. Bursts of physical exertion “run up stairs to class.” and which may be an associated
“Past couple of days, though it doesn’t seem like anything in particular is symptom
causing it.”
Relieving Factors Pronventil inaler. “Once I use my inhaler it only takes a minute or two for my
breathing to go back to normal…that’s not what’s been happening recently ,
though.”
Treatment Proventil inhaler
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Proventil 90mcg 2 inhalations Every 4 hours prn 25.5 years Asthma: wheezing, SOB
Tylenol 500mg 2 tablets po Every 6 hours prn PRN Headache
Advil 200mg 3 tablets po Every 4 – 6 hours prn PRN Menstrual cramps
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, Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Asthma: Diagnosed with asthma at age 2 and ½ years
Diabetes: Diagnosed at 24 years of age. Has not taken medication for diabetes for 3 years. Manages diabetes by avoiding sugar and trying to stay
active. Does not self monitor blood glucose.
Hospitalizations: Patient estimates being hospitalized 5 times for asthma as a child. Last hospitalization age 16 years. Denies previous intubation
for asthma.
Chest X-ray: at age 16 years
Surgical: Denies
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Patient moved back home with mother and little sister after the death of her father. Finds support through family, church, and her spirituality. Patient
is employed and attends college.
Exercise: Low level of activity: Exercise consists of “Being on feet at work and walking around campus.”
Tobacco: denies use of tobacco products, vape, or e-cigarette. Not exposed to second hand smoke at home.
Recreational drug use: Smoked marijuana for 5 to 6 years, last smoked marijuana at age 21 years of age. Stopped because “It just wasn’t fun
anymore, plus it bothered my asthma.” Denies every using other illicit drugs or inhaling substances.
Environmental: Carpet in bedrooms, no pets, changes bed linens once a week. “ We keep it pretty neat and tidy.”
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
Asthma: younger sister; no other family members with asthma
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