Document Preview

Episodic/Focused SOAP Note

Patient Information:

Initials: E.D. Age:22 Sex: female Race: white

S.

CC: Ms. ED is here for sore throat over one week and half ago.

HPI: Ms. ED is 22-year-old Caucasian female. She is here because of sore throat for over one week and half. She also has compliant of other symptoms, include bad cough, nasal congestion and lost voice due to swollen throat. She states her cough is productive with yellow sputum and worsened with swallowing and speaking. She smoked cigarettes yesterday. She denies of fever or take any OTC medication. Denies SOB, chest discomfort, wheezing or history of asthma.

Current Medications:

Cyanocobalamin 100mcg/ml Injection subcutaneously every 30 days for anemia

Ergocalciferol 50,000unit by mouth weekly x6 weeks, then 50,000 PO monthly for vitamin D deficiency

Loratadine 10mg by mouth daily as needed for allergic rhinitis/cough Phentermine HCL 37.5mg by mouth daily for weight loss

Triamcinolone Acetonide 0.025% 1 application topically to affected area 2 times per day for arm rash

Allergies: No Known Drug Allergy

PMHx: Urinary tract infection, Obesity, Chlamydial infection, Anxiety disorder.

PSHx: Denies of past surgical history.

Pt reported had polio and tetanus vaccine.

Soc Hx:

Patient denies of drink alcohol. She smokes 1-9 cigarettes per day. She is on medications to control her weight. She exercises regularly.

Fam Hx: No chronic disease was reported……….. Continue