Soap Notes

Topics: Medical terms, Symptoms, Medicine Pages: 2 (394 words) Published: August 11, 2010
Beth Bryan with office note on Jimmy McGann from 12/29. His DOB is 12/03 age is 35 and he is male. CHIEF COMPLAINT: Non productive cough with congestion.
SUBJECTIVE: This patient with history of Aids status post newmosotisis kerantina ammonia. Hairpes esogasutisis perrectual herpes and cmv hepatisis. Is seen today for the first time in four an half months. The patient indicates that mid November he stopped all his medications because, “I just got confused about the dosing”, when I asked why he had not called he said he just never thought about it. He relates that his most acute problem right now is that development of non productive cough associated with congestion. There been no fevers, chills, pluratic chest pain, anorexia, nausea, voimting, increased diaherra or, GU symptoms. OBJECTIVE: HEENT are basically unrealiving with no posterior drainage. Neck supple good range of motion. No significant adanapate. Back exam benign. Chest is relatively clear although he does have diminshed breath sounds in the basis. Cardo vascular S1, S2, without rubs or murmurs. Abdomen bowels sounds present, abdomen is soft non tender with no guarding or rebound. Extremities are unrealvealing. Skin clear. No rashs, ulcerations, or lesions at this time. ASSESMENT:

1.)Broncitis at this point I think the prudent thing is to address this problem acutely with Zithormax and Vicodin tusk cough supresent. 2.)History of acquired immunodefiency syndrome. Once again I reviewed how critical it is for him to maintain complaince and follow-up. I have expressed that if I’m going to make 100% commitment to him. He likewise has to commitment to his own health care. As such, if he fails to return and follow-up will have to seek an alternative physician to provide his care. He indicates that he understands my concern and anxiety. I have stated that were going to deal with his acute illness and then I will place him back on his medications. Repeat labs today to assess his status. 3.)...
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