SOAP NOTES TEMPLATE
Location: Chest and Lungs
Duration: Two days ago. Experiencing episodes lasting several minutes every 4 hours since
original episode. Waking up twice a night with asthma the past 2 nights.
Charac
...
SOAP NOTES TEMPLATE
Location: Chest and Lungs
Duration: Two days ago. Experiencing episodes lasting several minutes every 4 hours since
original episode. Waking up twice a night with asthma the past 2 nights.
Characteristics: Shortness of breath not relieve by inhaler prescribed use; Wheezing, inability to
lie flat, dry nonproductive cough; waking at night due to shortness of breath; asthma interferes
with activities of daily life. Chest tightness, not pain.
Aggravating Factors: Exposure to cats or dust; Burst of physical exertions “when hurrying up
or walking upstairs”.
Relieving Factors: Usually inhaler, nothing currently
Treatment: Proventil 90mcg inhaler 3 puffs every 4 hours
Current Medications
Medication Dosage Frequency Length of
Time Used
Reason for Use
Proventil 90mcg 3 puffs every
4 hours PRN
25.5 years Asthma: Wheezing,
Shortness of breath; Cats
Tylenol Gel
Caps ES
500mg 1 capsule
PRN
< few weeks
ago
Headache
Advil 200mg 3 tablets
Three Times a
day
PRN Menstrual Cramps
Metformin Unknown 1 tablet BID 1 year age 24 Type 2 Diabetes
Past Medical History (PMHx) –
Asthma: Diagnosed age 2.5 years
Diabetes: Diagnosed age 24 years. Has not taken medications for diabetes for 3 years. Manages
diabetes by avoiding sugar and trying to stay active.
Foot Wound: A few months ago, states it is healing
Hospitalizations: State” A bunch of times as a child for asthma”; last hospitalization was age 16
years.
Chest X-ray age 16 years
X-ray foot few months ago
Surgery: Denies
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