Question

my professor wants me to correct a respitatory soap note that i handed in, and i am confused with what he is asking for, if someone can tell me if my work is correct? if not help me fix it?

this is what i handed in: SUBJECTIVE:  Patient is a 45-year-old-caucasion female. Patient has been experiencing cough with excessive sputum, shortness of breath, fever, achy chest pain, and a headache upon wakening for the last 3 days. Patient explains that pain increases when she is exerting energy such as climbing a flight of stairs or chasing after her 2-year-old niece. Her pain is constant, and prominent when she inhales. Patient reports that when she is sedentary, pain is eased.

Patient denies family history of asthma, emphysema, or COPD. Patient is up to date on all vaccines, has no allergies, or past surgical history. Patient reports smoking at least, ½ a pack of cigarettes a day for the past 10 years. Patient denies alcohol consumption, and reports no use of drugs.

Patient self-treated with Tylenol every 6 hours for fever and cough, which help limit her symptom effects.

the teacher wants it in THIS format, did i fill it out correctly? and what would i write for review of symptoms?

PMHX: None

PSHX: None

Meds: Patient self-treated with Tylenol every 6 hours due to fever and cough

SHX: Patient reports smoking at least ½ a pack of cigarettes a day for the past 10 years, Patient denies alcohol consumption and reports no use of drugs.

FHX: denies family history of asthma, emphysema, or COPD

Review of systems:

Answer 1

Review of systems include 14 systems

1. Constitutional : denies weight loss or gain, fatigue, chills, night sweats, change in appetite etc

2. Eyes: denies any eye pain or vision problems.

3. Ears, nose, mouth, throat: denies ear pain, discharge, ringing, nose bleeding,  nose discharge, oral lesions, ulcers, throat congestion, tooth pain etc.

4. CVS: denies palpitations, leg pain, leg swelling etc.

5. Respiratory: wet cough, chest pain associated with exertion, exertional dyspnoea.

6. GI: denies nausea vomitting, constipation, diarhoea, dark colored stools.

7. GU: denies painful urination, burning sensation, urgent urination, urinary incontinence, incomplete bladder emptying etc. Denies menstrual bleeding pain, vaginal discharge after menopause irregular periods, missed periods.

8. MS: denies myalgia.

9. Skin: denies skin lesions, itching, nipple discharge etc

10. Neuro: has headache upon wakening. denies memory loss, dizziness, seizure etc.

11. Pshychiatric: denies anxiety, irritability, etc.

12. endocrine: denies excessive thirst or hunger, cold or heat intolerance.

13. Hematologic or lymphatic; denies lymphatic swellings or bruising etc.

14. immunologic: denies allergies or HIV exposure