SOAP NOTE: Chronic Obstructive Pulmonary Disease

SOAP NOTE: Chronic Obstructive Pulmonary Disease


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Name:   K. B  Pt. Encounter Number: 315/2018
Date:  01/05/2018 Age:  76 Sex:  Female

“I have experienced difficulty in breathing, cough that is continuously increasing, sputum production as well as instances of wheezing during exhalation and inhalation. There is also chest pain”



The patient illustrated that three months ago, such symptoms existed which prompted hospitalization and was treated and discharged…


Due to chest pain as well as headaches, the patient has been taking ibuprofen 400mg three times in a day.


Allergies:   No known food or drug allergies.

Medication Intolerances: None.

Chronic Illnesses/Major traumas : None



  The patient had been hospitalized twice. The two admissions occurred in June 2015 and February 2017 and were due to bronchitis both of which were treated successfully. There is no history of surgery.

Family History

Her mother died of hypertensive heart disease while the father died in a tragic road accident…

Social History

The patient is a retired don having taught in a nursing school for many years…


The patient reports reduced energy with no marked change in weight.


She reports presence of chest pain that is intense when coughing. No palpitations or edema.



There is good skin turgor. The skin is wrinkled. No visible lesions, bruises or rashes.


She reported coughs and wheezing which had lasted three days. There also existed difficulty in breathing and shortness of breath. No history of tuberculosis.


No reports of use of corrective lenses or experience of blurred vision.


No instance of constipation, abdominal pain, hemorrhoids, diarrhea, nausea and vomiting.


No discharge or pain reported from the ear.




Patient denied presence of any urinary symptom. Patient in menopause, no vaginal discharge, less sexual activity.




The patient denied swollen or bleeding gums. She had no hoarseness of voice. No discharge from the nose.


She denied presence of muscle pain. No stiffness of joints. No history of fracture.


She knows and conducted self-breast examinations. No lumbs on the breasts.


She reported instances of headache that had been on and off for the last two days. No history of seizures.


She is HIV negative based on the test that was done in February 2018. Has no history of blood transfusion or even donation. No swollen lymph nodes.


The patient denied episodes of anxiety, suicidal ideations or difficulty in maintaining sleep.

Weight  :   69   BMI Temp  : 98 BP  : 115/78
Height  : 5.7’’ Pulse  : 76 Resp  : 20
General Appearance

A healthy looking female geriatric with no distress or display of low energy…


She has clean, warm and intact skin. No rashes, bruises or lesions.


Head is normocephalic. ….


On auscultation, the S1 and S2 are heard. Regular heart rhythm and rate. No facial edema. Capillary refill of 2 seconds.


There is labored and noisy breathing. The wheezing can be heard both during inspiration and exhalation.


No distention in the abdomen. Bowel sounds can be heard from all the quadrants.


No lumbs on the breast.


The system was not explored due to request from the client but reported no alarming issue from the same.



During the entire period of assessment, full range of motion is observed from the four extremities.


The speech is clear. She has a normal gait with stable balance.


Patient is fully oriented. She is well groomed and maintains eye contact throughout. She responds to questions appropriately.

Lab Tests
Arterial blood gas analysis- is pending
Special Tests

Chest X-ray– pending

Spirometry- FEV1=78% AND FEV1/FVVC=0.5

Chronic Obstructive Pulmonary Disease.

Refers to inflammatory disease of the lung and obstructs airflow. It manifests in the form of difficulty in breathing, wheezing and sputum production. According to Sam et al., (2017), the condition originates from exposure to irritants…

Lung Cancer.




Final Diagnosis   



Further testing






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