Focused SOAP Note

S – Subjective Data

Patient Information

J.D. is a 45-year-old African male.

Chief Complaint (CC)

The patient reports the presence of a chronic cough and shortness of breath for the last two weeks.

The history of present illness (HPI)

The case J.D. is a 45-year-old man who presented with a two-week history of a progressive, productive cough with yellowish sputum. He complains of coexisting exertional dyspnea and occasional chest pain, which is triggered by coughing, without radiation and pleuritic features. The cough is especially nocturnal and somewhat relieved by antitussive therapy available over the counter. He scores his symptoms at 5/10. He refutes coughing up blood, noticeable weight loss, and night sweats. Clinical presentation is suggestive of an acute lower respiratory tract process.

Current Medications

The patient denies the use of any drugs other than discomfort-related paracetamol 500mg orally, but denies taking any unspecified cough syrup over the counter.

Allergies

Denies any drug, food, or environmental allergies.

Past Medical History (PMHx)

The patient does not have a known chronic medical history, history of any surgical procedures, or hospitalization.

Social History

J.D. works as a taxi driver and has a smoking history of about 20 packs a day, about 20 pack-years. He denies frequent alcohol abuse and lives with his family. His tobacco consumption is another major risk of respiratory pathology (Center, 2026).

Family History

The patient has heard that his father had high blood pressure, and his mother had type 2 diabetes mellitus.

Review of Systems (ROS)

The patient does not deny fatigue, but does not have fever, chills, or unwanted weight loss. He denies the presence of upper respiratory symptoms like nasal congestion and sore throat: no chest pains or palpitations. Pulmonary findings consist of a productive cough and dyspnea. There are no abnormalities of gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, and integumentary systems (Khan et al., 2024).

O – Objective Data

Vital Signs

The temperature is 37.8 deg C, blood pressure 130/85mmHg, Heart rate 96 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation in blood 94 per cent on room air, showing mild hypoxemia.

Physical Examination

The patient is looking slightly ill with observed increased work of breathing. HEENT is not remarkable, without any cervical lymphadenopathy. Heart sounds normal rate and rhythm without murmurs, rubs, or gallops. Pulmonary physical examination reveals bilateral basal crackles and shallow air entry, which is corroborated by the lower airway involvement. The abdomen is tender and non-tender and does not have organomegaly. Neurological examination is that of an alert and oriented person without focal deficits. The skin is warm and well perfused with no cyanosis or lesions.

A – Assessment

The clinical picture of the patient is most likely to be acute bronchitis, in which case the patient has a productive cough, slight fever, and the findings during the auscultation are rather indicative of inflammation of the airways. The etiology of acute bronchitis is mainly viral, but in some groups of the population, bacterial superinfection is possible (Singh et al., 2024).

Differential Diagnoses

Pneumonia is one of the most important differential considerations due to the nature of cough, low-grade fever, and crackles on auscultation, and a radiograph was not possible without confirmation. The possibility of chronic obstructive pulmonary disease (COPD) exacerbation is also discussed, as the patient has a long smoking history and the signs of respiratory problems. However, it has never been diagnosed with this problem before (Park et al., 2025). In the background of a persistent cough, pulmonary tuberculosis should be taken into account. However, the lack of constitutional symptoms of the disease, including night sweats and weight loss, reduces the likelihood of the disease.

P – Plan

The diagnosis will involve a chest radiograph to determine whether it is bronchitis or pneumonia, a complete blood count to evaluate whether it is an infection or inflammation, sputum culture and sensitivity to determine whether some bacteria cause it. Pharmacologic therapy aims at the introduction of amoxicillin 500mg orally three times a day during the period of seven days to treat potential bacterial infections, as well as a short-acting bronchodilator (salbutamol inhaler) to treat bronchospasm and airflow clearance. Paracetamol 500 mg will be continued on a need basis as an over-the-counter medication to treat fever and discomfort. Non-pharmacological treatment methods involve instructing the patient to stay well hydrated, get enough sleep, and avoid environmental respiratory irritants. Smoking cessation counseling is highly highlighted because it has a great impact on the respiratory morbidity and progression of a disease. The patient was advised on the significance of taking medicine regularly, checking her symptoms, and early reporting of early warning signs like the increase in dyspnea, a prolonged fever, or coughing up sputum. Cases that do not resolve or show signs of complications will be referred to a pulmonologist. Follow-up would be in 5-7 days to review progress with clinical and review of diagnostic results, with the recommendation to revisit earlier in case of symptom aggravation.

References.

Khan, M. R., Haider, Z. M., Hussain, J., Malik, F. H., Talib, I., & Abdullah, S. (2024). Comprehensive Analysis of Cardiovascular Diseases: Symptoms, Diagnosis, and AI Innovations. Bioengineering, 11(12), 1239. https://doi.org/10.3390/bioengineering11121239

‌ Singh, A., Avula, A., & Zahn, E. (2024, March 9). Acute Bronchitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448067/

National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. (2014). Respiratory Diseases. Nih.gov; Centers for Disease Control and Prevention (US). https://www.ncbi.nlm.nih.gov/books/NBK294322/

‌Park, H., Jo, S. M., Jin, K. N., Lee, H. J., Lee, H. W., Park, T. Y., Heo, E. Y., Kim, D. K., & Lee, J.-K. (2025). Distinct risks of exacerbation and lung function decline between never-smokers and ever-smokers with COPD. BMC Pulmonary Medicine, 25(1). https://doi.org/10.1186/s12890-025-03604-1

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Focused SOAP Note Template

Patient Information:
Initials, Age, Sex, Race

CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache” not “bad headache for 3 days”). For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (eg., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: Pounding, pressure around the eyes and temples

Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

Timing: After being on the computer all day at work

Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., anaphylaxis, rash, etc.).

Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

Timing: After being on the computer all day at work

Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed.

Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed.

Fam Hx: Identify illnesses with possible genetic predisposition, and 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.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)).

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General; Head; EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period (MM/DD/YYYY).

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT: etc.).

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Include documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidence-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.