Soap Note of a Patient Suffering From Pneumonia

Running head: SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA
SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA
Name of the Student:
Name of the University:
Author’s Note:

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SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA
Identifying Data: Thomas Jones
Age: 44 years
Gender: Male
Occupation: Manager in a printing shop on Hornsby
Marital Status: Married
Subjective: Thomas Jones wife has observed various changes such as difficulty in
breathing, fatigue, continuous nausea that led to doctor consultation
HPI: Pneumonia
Past Medical History: Thomas had a past history of asthma and was a chain smoker
Childhood Illnesses: In childhood, he had suffered from smallpox and encountered some
minor accidents while playing basketball.
Injuries: He had a back injury while playing
Surgeries:
He was operated in his early twenties due to gall bladder stone
Hospitalizations:
He was hospitalised a couple of time in the nearby State hospital during his life where
treatment was offered to him in an effective manner
Psychiatric:
He does not have any issue related to psychiatry
Health Maintenance:

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SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA
He had lived a regular life and had maintained his life in an appropriate except for his habit of
smoking.
Immunization status: Complete
Dental Exams: Two months ago
Last eye exam: Optimised
Family History: His family had a history of diabetes
Personal and Social History:
Educational level: He is a graduate
Personal interests:
He has a hobby of collecting stamp and coin, which he kept as his personal collection.
Moreover, he was interested in sailing and travelling; thus, he used to travel neighbouring
locations from his early childhood.
Lifestyle –
He had an average lifestyle where he exercised on a daily basis, where he walked almost 5
km from and to his workplace. However, his smoking habit was detrimental to his lifestyle
and affected his respiratory tract to a large extent. He consumed a normal diet; however, due
to lack of information, the dietary content was not up-to-the-mark.
O: Objective
Vital Signs
Blood Pressure: 120/80 mmHg
Temperature: 105 °F
Pulse: 70
Respirations: 21
Height: 5 feet 10 inches