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MSN 572 Immersion Sick SOAP

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SOAP note Subjective ID: Dan A. is a 42-year-old Caucasion-Hispanic male who presented with coughing and wheezing during exercise for the last two months. He is at the clinic alone and is a reliable source for his health. CC: “I have trouble breathing while exercising.” HPI: Dan A. is a 4...

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  • March 18, 2024
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  • 2023/2024
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SOAP note


Subjective
ID: Dan A. is a 42-year-old Caucasion-Hispanic male who presented with coughing and

wheezing during exercise for the last two months. He is at the clinic alone and is a reliable

source for his health.

CC: “I have trouble breathing while exercising.”

HPI: Dan A. is a 42-year-old male present today at the virtual clinic due to new onset of

symptoms during exercise. Patient developed trouble breathing with dry cough and wheezing

while jogging which started 2 months ago. He usually joggs 5K each day without any difficulties

in the morning or in the afternoon. He runs 5 days a week and 30 mins each time. He reports the

cough and wheezing stops within a minute if he stops his exercise. He will continue running

when symptoms subside. Symptoms get worse when exercise is continued. He reports he is able

to continue with other daily activities without difficulties.

PMH:

Medical problem list: Childhood Asthma

Surgeries and hospitalizations: Appendectomy and MCL tear repair in his mid 20s without

complications.

Immunizations:Up to date. Flu vaccine last October. Received Covid booster.

Allergies: Reports seasonal allergy during March to August. Controlled with Flonase.

Medications: OTC multivitamin.

Family History: Mom is 72-year0old with migraines. Dad died at age of 52 due to emphysema

with a long history of smoking. Maternal grandmother and grandfather died due to old age with

no known medical history. Paternal grandmother died due to old age. Paternal grandfather passed



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