(SOAP NOTE) NR511 KATIE 65 YO FEMALE (CC Coughing worse at
night, fatigue and gets winded daily while waking up)
Patient Information: Katie, 65yr, female S:
CC: Patient states “I began coughing 1 week ago and its worse at night. My chest is starting to
hurt from all of the coughing”. She also is c/o fatigue and getting “winded” while walking daily
and no energy to attend her exercise classes.
HPI:
O: 1 week
L: Chest
D: 1 week (Have you had these symptoms in the past? If so, what months or seasons?)
C: Fatigue, winded, pain in chest (Is your cough dry or productive? Can you describe what the
cough sounds like? If your cough is productive, what color is your sputum? Have you noticed
any blood in your sputum? Besides your chest hurting, does anything else hurt (throat, sinuses,
and ears)? Any chills, body aches, night sweats? Do you hear any wheezing in your chest?
Have you felt nauseous, any vomiting or diarrhea? Have you noticed any swelling in your
ankles or feet?)
A: walking, exercising, worse at night (Does anything else make your cough worse? Eating,
drinking?)
R: none reported (Does anything relieve the cough?)
T: none reported (Have you taken anything for your cough?)
S: Severe, affected her daily activities, and sleep. (Can you rate the pain from 0 to 10? Are
these symptoms changing your ability to do your normal activities?)
Current Medications: Multivitamin, Evista 60 mg daily, HCTZ 25 mg daily
Allergies: Demerol, pollen
PMHx: Chicken pox, measles and rubella during childhood. Osteopenia, HTN, and
hyperlipidemia.
Surgical Hx: Tonsillectomy and cholecystectomy. Hospitalized for childbirth and surgeries
Social Hx: Lives with husband John, and married daughter and her family. She watches her
grandkids when Mary and her husband are at work. Her husband and son-in-law smoke, but
not in the house. She does not smoke or drink alcohol.
ROS:
CONSTITUTIONAL: Reports fatigue. Denies weight loss, fever, and chills. She did not check
her temperature.
HEENT: Head - No headache, dizziness, or syncope. Eyes – no visual loss, blurred vision, or
double vision. Ears – no hearing loss, no ear discharge, or swelling. Nose – no sneezing,
congestion, or runny nose. Throat - no report of sore throat, or difficulty swallowing.
CARDIOVASCULAR: Reports chest pain. No palpitations or edema.
RESPIRATORY: Reports cough and shortness of breath.
GASTROINTESTIONAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or
blood in stool.
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