SOAP

## SOAP Note Example - Family Medicine **Date:** 1 November 2024 **Subjective:** * Patient presents today with a chief complaint of a persistent cough and fatigue for the past two weeks. Patient reports the cough is dry and occasionally produces a small amount of clear mucus. Patient denies fever, chills, or shortness of breath. Patient reports feeling tired and lacking energy, impacting daily activities. * Patient has a history of seasonal allergies, managed with over-the-counter antihistamines. No prior hospitalisations or surgeries. * Patient is currently taking loratadine 10mg daily for allergies. No herbal supplements reported. * Patient is a non-smoker and drinks alcohol socially. Patient is employed full-time and reports a supportive home environment. * Patient reports no known allergies to medications or environmental factors. **Objective:** * **Vital Signs:** Temperature: 37.0°C, Blood Pressure: 120/80 mmHg, Heart Rate: 78 bpm, Respiratory Rate: 16 breaths/min, SpO2: 98% on room air. * **Physical Examination:** General: Alert and oriented. HEENT: Mildly injected conjunctivae. Throat is clear. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Abdomen: Soft, non-tender. Skin: No rashes or lesions noted. * **Laboratory and Imaging Results:** No labs or imaging performed today. **Assessment:** * **Diagnosis:** Upper Respiratory Infection (URI) likely viral etiology. * **Clinical Impression:** Patient presents with symptoms consistent with a mild viral URI. No evidence of pneumonia or other complications at this time. **Plan:** * **Treatment Plan:** Advised patient to rest, stay hydrated, and use over-the-counter cough suppressants as needed. Recommend symptomatic treatment. * **Patient Education and Counseling:** Educated patient on the self-limiting nature of viral URIs and the importance of hand hygiene to prevent spread. Reviewed signs and symptoms that would warrant a return visit (e.g., high fever, difficulty breathing, worsening cough). * **Referrals:** No referrals needed at this time. Follow-up in one week if symptoms worsen or do not improve.