SOAP Note: Assessment and Plan for Pneumonia Patient

This SOAP (Subjective, Objective, Assessment, Plan) note presents a case study of a 44-year-old male patient, Thomas Jones, diagnosed with pneumonia. The subjective section details the patient's wife's observations of symptoms like difficulty breathing, fatigue, and nausea. The history includes past medical history of asthma, smoking, and childhood illnesses. Objective data reveals vital signs such as elevated temperature, abnormal blood pressure, and respiratory rate. The assessment includes diagnostic tests like chest X-rays and blood tests. The plan focuses on smoking cessation, airway clearance, infection risk management, and antibiotic administration, along with promoting normothermia and fluid balance. References to relevant medical literature are included to support the assessment and plan.

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:

1SOAP 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:

2SOAP 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

3SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA
Weight: 84 kg
BMI: 12.1
This indicates that Thomas Jones has a normal weight; however, he was losing weight.
Physical Examination:
A thorough physical examination is remarkable in nature and he was suffering from high
temperature, cough, and shortness of breath and loss of energy. This indicated that he was
suffering from pneumonia (Tordoff & Williams, 2018).
A: Assessment:
Diagnostic Tests:
According to Torres et al. (2016), the diagnostic tests that can be conducted for identification
of pneumonia are:
 Endoscopy of chest
 Blood test
 Chest X-ray
 Pulse oximetry
 Test the lungs
 Sputum test
 Physical observation of vital stats
P: Plan
One of the factors that complicated the condition is smoking; therefore, smoking cessation
strategy needs to be taken into account. The care plan needs to be is airway clearance, risk of
infection, breathing patter and administration of antibiotics. The stage of pneumonia need to

4SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA
be evaluated and as per the condition, care plan needs to be formulated. The diagnostic tests
need to be done and a complete respiratory assessment needs to be conducted for detecting
any changes by the physician. Gotz et al. (2016) opined promoting normothermia and cluster
care need to be given to Thomas for improving his medical condition. Glurich, et al. (2019)
opined that optimisation of fluid balance and encouraging coughing to remove phlegm need
to be done.

5SOAP NOTE OF A PATIENT SUFFERING FROM PNEUMONIA
References
Glurich, I., Shimpi, N., Scannapieco, F., Vedre, J., & Acharya, A. (2019). Interdisciplinary
care model: pneumonia and oral health. In Integration of Medical and Dental Care
and Patient Data (pp. 123-139). Springer, Cham.
Gotz, D., Jin, B., Zha, H., Shu, L., & Cao, N. (2016). Understanding care plans of community
acquired pneumonia based on Sankey diagram.
Tordoff, A., & Williams, L. A. (2018). Community-acquired pneumonia in adults: Diagnostic
reliability of physical examination techniques and their teaching in academia.
Torres, A., Lee, N., Cilloniz, C., Vila, J., & Van der Eerden, M. (2016). Laboratory diagnosis
of pneumonia in the molecular age. European Respiratory Journal, 48(6), 1764-1778.