SOAP Note on Pneumonia

Date: 20/04/2020

The 55-year-old patient visits a health facility in the morning. He is white, 7’2 tall and weighs 149.7 lbs.

Referral: None

Source and Reliability: Lab tests and symptoms from the patient.

S (Subjective):

Chief Complaint: The 55-year-old male patient with a history of heart disease complains of fever, sweating, and/chills, severe cough, chest pain when coughing or breathing, shortness of breath and/or difficulty in breathing, lack of appetite, frequent fatigue, nausea, diarrhea, or vomiting, and feeling weak.

HPI: The patient says that he has been coughing for the past three weeks. The cough produced phlegm. He also says he has been feeling weak and fatigued. He visited nearby health facilities and got some medications, but the symptoms persisted to the point he lost appetite and started experiencing nausea and diarrhea. He also said he had a difficulty while breathing. However, he confessed that his chest pains were mild and he had not at any point experienced vomiting.

Objective: The observation is that the patient is likely to be suffering from pneumonia: This is because of abnormal sounds in his lungs, the symptoms he confessed and lab tests.

Assessment: The health providers saw it necessary to give the patient over-the-counter drugs like antibiotics and antivirals. He was also given breathing treatments because of his difficulty to breathe.

Plan: To successfully treat the patient, the health providers recommended rest as much as possible to allow the body to fight infection and heal. The patient also needs to take a lot of fluids and a cup of caffeinated coffee to improve breathing. Moreover, they should ensure they breathe in fresh air all the time, gargle salt water to help wash away the pleghm and stay away from smoking or any other type of smoke.