DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: This is a followup appointment for this very pleasant (XX)-year-old woman who we treat for bronchiectasis. In the interim, since her last appointment, she did have a polysomnography with a CPAP titration. She had an RDI of 15.8 events per hour. She was brought back in and had a CPAP titration and is now using her CPAP at a setting of 7 cm of water with C-Flex at 3. She is continuing with her rotating course of antibiotics. In March, she took Ceftin 500 mg b.i.d. for 10 days, and in April, she took Levaquin 500 mg a day for one week. At the present time, she is in between courses.
OBJECTIVE: Weight is stable at 124. Saturation on room air was 97%. Pulse is 90. Respiratory rate is 20. Blood pressure is 134/70. HEENT: Without exudates or lesions. Neck: Supple. No supraclavicular adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No clubbing, cyanosis, or edema.
ASSESSMENT:
1. Obstructive sleep apnea, now on CPAP at a setting of 7 cm of water with C-Flex at 3.
2. Bronchiectasis, on rotating antibiotics.
3. Recent transient ischemic attack.
4. Cough.
5. History of Mycobacterium avium complex.
6. History of asthma.
7. Gastroesophageal reflux disease.
PLAN: The patient will continue her course of rotating antibiotics. She will also continue to use her CPAP, which was only begun one week ago. She has no complaints today regarding the mask or the headgear, but we do want to keep a close eye on her, and we will see her back in three weeks’ time to make sure that no problems develop and she does not abandon her CPAP. We will keep you abreast of her progress.
Pulmonary SOAP Note Sample #2
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: This is a routine annual examination for this very pleasant (XX)-year-old gentleman with severe COPD. He does inform us that since his last visit, he did have a left hip repair, and he also informs us that he has recently been hospitalized for five days at the beginning of January. He now states that he has recovered from his exacerbation, he is feeling well, and he does tell us that he is now off of Coumadin.
OBJECTIVE: Weight is stable at 210. Saturation on room air is 94%. Pulse is 82. Respiratory rate 22. Blood pressure 130/70. HEENT: Without exudates or lesions. Neck: Supple. No supraclavicular adenopathy. Lungs: Moderately decreased breath sounds but clear. Cardiac: S1, S2. Abdomen: Benign. Extremities: No clubbing, cyanosis, or edema.
ASSESSMENT:
1. Severe chronic obstructive pulmonary disease.
2. Left hip repair.
3. Hypoxemia.
4. History of pulmonary embolism, off of Coumadin.
5. Obstructive sleep apnea, on one liter oxygen at bedtime.
6. Coronary artery disease.
7. Gastroesophageal reflux disease.
PLAN: We are going to give him a trial of Spiriva. He was demonstrated proper use of the inhaler here in the office and was provided with samples as well as a prescription. He is going to follow up with his pulmonologist up north very shortly, and we will be seeing him again in the fall once he returns. We will keep you abreast of his progress.
Pulmonary SOAP Note Sample #3
DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: This is a pleasant (XX)-year-old gentleman who we follow for obstructive sleep apnea. He tells us today that he has new problems with the mask. He is having a little bit of difficulty with too much condensation collecting in his tubing. He also tells us today that he has a pain in his lungs. This has been going on for about approximately two months’ time. He denies any fever, chills, or hemoptysis. You will recall that he was a former smoker, was smoking 3 packs per day, that is 3 PPD, for 40 years, and he did quit 4 years ago.
OBJECTIVE: Weight is stable at 208, pulse is 48, respiratory rate 20, and blood pressure 120/72. Saturation on room air is 98%. HEENT: Without exudates or lesions. Neck: Supple. No supraclavicular adenopathy. Lungs: Clear. Cardiac: Regular. Abdomen: Benign. Extremities: No clubbing, cyanosis, or edema.
ASSESSMENT: Obstructive sleep apnea, 100% adherent, BiPAP setting is 17/13 cm of water.
PLAN: The patient will continue to use his BiPAP. We will be in touch with his home care company. They need to educate him on how to set the humidity. We have also asked him to have a chest x-ray for his complaint of pain. Although it sounds musculoskeletal in nature, we need to be sure. We will see him back after the chest x-ray, and we will keep you abreast of his progress.
