Posted: December 16th, 2022
soap note example -cough Please go to Bates' Visual Guide to Physical Examination at batesvisualguide.com. After logging in, go to the Objective Structured Clinical Examinations (OSCE) tab, log in again, and complete the OSCE titled "Cough". Please document this encounter using the SOAP format. Unless specified in the case study, the patient's PMH, PSH. FH, SH, and ROS are "normal" or non-contributory. Your task is to "create" a "normal" (don't use that word!) PMH, PSH, FH, SH, and ROS for your documentation for this encounter (See examples in your Bates' text and pocketbook). In other words, I need to see that you know what information belongs under each of these categories and that you know how to document appropriately. So, create or make up, normal findings for these and document them correctly. Recall these OSCE written assignments are to be Comprehensive SOAP Note. When you document the physical exam you will include any abnormalities discovered in the OSCE but will also include so-called "normal" findings in each system. Here too, what is expected is evidence that you are proficient in communicating both normal and abnormal findings (without using those words!). Under "Assessment" you will choose the most likely diagnosis which is confirmed by the data presented and assessed. Using the tool found at either http://www.icd10data.com/ (Links to an external site.) or https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx (Links to an external site.) you will also include the ICD 10 code appropriate to that diagnosis. For example, if your assessment for an encounter is "Acute Pharyngitis" you would document this as "Assessment: Acute pharyngitis (ICD 10 Code J02.9)". For our purposes you will identify (list) the data to the diagnosis which supports it. Please see grading rubric. The differential diagnoses, as you are aware, are diagnoses which are possible given the data. It is usually listed from the MOST probable to the LEAST probable given the data at hand or data being derived from diagnostics. But they are data driven. If there is no data to support it, the diagnosis should not be considered. In a patient encounter SOAP note, many clinicians place their differential diagnoses within the "Plan" and keep the current working diagnosis in the "Assessment". (This is my preference and practice). This helps the biller/coder in the practice quickly identify the current diagnosis without billing for diagnoses which are not confirmed. For example, the data at hand may confirm an abnormal PAP (ASCUS), but you are concerned about cervical cancer. Under the heading of "Assessment", cervical cancer would not be listed since the data does not yet confirm it. Rather, under section heading of, "Assessment" it would be "Papanicolaou smear of cervix with atypical squamous cells of undetermined significance, ICD 10 Code R87-610)". But under "Other considerations" or "Differential Diagnoses" in you would obviously communicate your malignancy concern. Here too, you will need to link or document your data which supports the consideration of the differential and provide the appropriate ICD 10 codes). You will not be documenting the "Plan", other than diagnostics. Leave the pharmacotherapeutics and surgeries or therapies for your next class. It is beyond the scope of our course. After you have chosen your diagnostic test(s) please indicate what specific finding/result from the test would support (or refute) your diagnostic concerns. A title page will be necessary and should follow standard APA format. An abstract is not necessary. You may single space the document but please separate the major sections by a double space. Headings should correspond to the major sections of the SOAP format. Please submit your SOAP note using a file upload under Assignments and in the following format: (1) biographical and identifying data, (2) subjective data - with its subcategories, (3) objective data - with its subcategories, (4) assessment, and (5) plan. Refer to your texts and the presentation "SOAP Notes and Oral Presentations" for more detailed information. Please provide a reference page. See SOAP NOTE FORMAT under "Course Resources and Information" for format to use for the SOAP note
Rubric Written SOAP Note Assignments (3) Written SOAP Note Assignments (3) Criteria Ratings Pts This criterion is linked to a Learning OutcomeAPA format and grammar/spelling rules followed 8 pts This criterion is linked to a Learning OutcomeComplete and accurate biographical data 12 pts This criterion is linked to a Learning OutcomeSubjective data includes pertinent data including chief complaint, history of present illness, past medical history, social and family/genomic history, past surgeries, and ROS. 20 pts This criterion is linked to a Learning OutcomeObjective data includes comprehensive physical exam, including vital signs, and completed diagnostics. 20 pts This criterion is linked to a Learning OutcomeAssessment (with ICD 9 code) is accurate and has supporting subjective and objective data described for the diagnosis. 8 pts This criterion is linked to a Learning OutcomePlan of care includes â€œOther Considerations" or "Differential Diagnosesâ€ which are supported by subjective and objective data described for the diagnoses. 20 pts This criterion is linked to a Learning OutcomePlan of Care includes appropriately chosen diagnostics with description of results which would affirm or refute the diagnoses. 12 pts Total Points: 100 I will include the soap note example and also the bates video transcript in written format. This transcript also has a differential diagnosis. Please follow the soap note, so all areas are coverd
SOAP Note: Cough
NURS 622: Advanced Health Assessment
Biographical and Identifying Data
02/18/2021 at 10:00 AM.
Ms. Chen is a 45 year old female of Asian ethnicity. She is single and works as a dispute
Current Address: 1532 Elizabeth Street Joliet, Illinois 60431
Phone number: (815) 555-1645
Self referred; reliable evidenced by recalling events easily, having consistent memories
and appearing open and pleasant during interview.
Chief Complaint: “I have been coughing for a week and just can’t seem to stop. I can hardly
sleep at night.” (Bates, n.d.). soap note example -cough
History of Present Illness:
Ms. Chen is a 45 year old female who smokes two packs of cigarettes per day for the past
ten years presenting today with a cough that has been occurring for one week. She reports
the symptoms began a little over a week ago with a runny nose and feeling a drip down
the back of her throat. Since then, symptoms have worsened and she has developed a
cough. The cough produces a yellow- green color with intermittent pink streaks in it that
Ms. Chen reports look like blood. She reports she does not see the pink streaks in every
sputum, but about 3-4 times per day. She denies pain in her chest. She reports the cough
seems to be worse at night and is causing disruption in her sleep. She has tried to sleep on
two pillows at night and reports this helps her head but is not relieving the disruption in
her sleep. Patient denies any fatigue preventing her from performing her activities of
daily living. She is experiencing wheezing and shortness of breath upon exertion during
activities such as walking up the stairs or doing yard work. Denies wheezing or shortness
of breath at rest when working at her desk. She has been taking over the counter (OTC)
decongestants and ibuprofen twice a day. Yesterday she checked her temperature at home
and it was 101 degrees Fahrenheit and fever is still present upon assessment today. She
denies having a history of these symptoms. Affirms she has seasonal allergies to pollen
and goldenrod but these are almost over for the season. Affirms a history of mild
childhood asthma with no hospitalizations or complications. She traveled to Shanghai a
few months ago with no known exposure to any ill people and no symptom development
during that time. She denies weight loss, night sweats or history of tuberculosis. Reports
her grandmother had tuberculosis as a child but was never in contact with patient while
having symptoms. Patient had a negative tb skin test 10 years ago. She denies any acid
taste or reflux symptoms.
Medications: No prescription medications. Patient has been using OTC recommended
dose of decongestant and ibuprofen BID for the past week.
Allergies: No known drug or food allergies. Seasonal allergies to pollen and goldenrod.
Tobacco Use: Smokes two packs of cigarettes per day for the past ten years with no
periods of successful cessation. No history of using chewing tobacco.
Alcohol and drug use: Patient reports one glass of wine three times per week. Denies
any illicit or prescription drug use.
Past Medical History
Childhood Illness: History of mild asthma as an elementary school aged child with no
Medical: Seasonal allergies in fall and spring.
Surgical: No surgical history
Obstetrical: No obstetrical history soap note example -cough
Psychiatric: No psychiatric history
Health Maintenance: TB skin test 10 years ago. All immunizations up to date. Receives
Influenza Vaccine every year, most recently in September 2020. Last pap smear in
January 2020, negative for intraepithelial lesion or malignancy; no HPV detected.
Mammogram in 2019, negative for masses.
Family Medical History: Maternal grandmother positive for tuberculosis when she was
in her 20’s. Currently alive at age 85. Patient denies any other family history of cancer,
respiratory disorders, cardiovascular disorders, kidney disease, diabetes, neurological
disorders, musculoskeletal disorders, gastrointestinal disorders, genetic disorders or
Personal and Social History: Born in Joliet, Illinois into a family with mother, father, and one
sister 2 years older than her. Has lived in Joliet, Illinois for her entire life. Currently lives alone
with 2 cats. Is single, has never been married and has no children.
Sexual orientation and gender identity: Born female, currently identifies as female.
Identifies as heterosexual.
Significant relationships and support systems: Reports being in a monogamous
relationship for about one year and sees him a few times per week. Reports feeling safe
and supported in the relationship. They have many mutual friends through their church
group where they met. Patient is actively involved in her Catholic church. Patient’s
weekly schedule includes church service and activities a few times per week. Patient
reports seeing friends after work for dinner at least twice per week, feels she has a
supportive friend group and states she rarely feels lonely.
Work history and occupation: Currently working full time as a dispute mediator and has
been in this job for about 20 years. Patient identifies her work as stressful but feels
fulfilled by her work. Patient identifies feeling secure in her job and supported by her
coworkers. Daily hours from 9 A.M. to 5 P.M, Monday through Friday. Denies being
around any ill coworkers or clients that she is aware of. Patient identifies the stress from
this job contributes to her habit of smoking cigarettes as a form of stress relief. Patient
reports her salary provides her a comfortable lifestyle, is in no major financial crisis, and
does not have significant financial stress.
Education: Completed high school. Completed 4 year college degree.
Lifestyle: Patient reports having many social events scheduled throughout the week after
work. Patient reports she rarely eats dinner alone, either meeting with friends, family or
her significant other. She reports no difficulty in keeping up with chores around the
house, enjoys working outside in her garden and with the landscape. Volunteers on the
weekends with her church and in her free time enjoys reading and painting. Patient
reports having adequate levels of energy for her weekly schedule. Reports sleeping
soundly 7-8 hours each night. No sleep concerns prior to presenting illness disrupting her
sleep. Reports her two cats sleep in the bedroom with her.
Travel: Traveled to Shanghai a few months ago with her family. Was fully vaccinated for
this trip, was not knowingly exposed to any diseases or in contact with any ill people.
Nutrition and exercise: Patient reports a well-balanced diet, makes an effort to eat all
food groups within each meal. Eats three meals per day. Prepares her lunch meals for the
week on Sundays. Eats out a few times a week socially, states she does not eat fried or
greasy foods when she eats out. Reports walking on the treadmill for an hour each
morning prior to going to work.
Alcohol and tobacco use: drinks one glass of wine three times per week. Smokes 2 packs
of cigarettes per day. Denies any illicit substance use. Has a cup of caffeinated tea in the
Safety measures: No history of injuries or major accidents. Reports she has never had to
be hospitalized for any reason. Pt reports she wears her seat belt every time she is in a
vehicle. Does not own a firearm. Does not have any prescription medicine in the home,
reports a few bottles of OTC medications in an upper bathroom cabinet. Cleaning
materials and other potentially hazardous chemicals are kept separate in a lower cabinet
in the laundry room. Patient reports she wears sunscreen and a hat that shades her face
Sexual history: Sexual practices include oral and pelvic intercourse averaging two times
per week. One sexual partner within the past five years. Uses condoms for contraception
and for prevention of sexually transmitted diseases. Sexual preference and history with
Review of Systems
General: Denies history of weight change, fatigue, appetite change, night sweats, fever
Skin: Denies history of rashes, bruising, dryness, itching, sores, pruritus, skin
discoloration or pigmentation changes, birthmarks, moles, erythema with or
without blistering. No history of lumps or masses.
Hair: Denies history of hair dryness, changes in texture, lice or other infestations,
trichotillomania, scalp rashes or irritation. No history of unexplained hair growth
or loss. soap note example -cough
Nails: Denies history of nail soreness, brittleness, cracking, lifting or injury. No
history of nail discoloration, yellowing, fungal infections, black or white lines.
Denies history of ingrown nails.
Head: No history of headaches, head injury, dizziness, or lightheadedness.
Eyes: Denies history of vision changes. Does not wear corrective lenses. Last eye
exam by her optometrist Dr. Johnson was November 2019. Denies pain, redness,
or excessive tearing. Denies history of glaucoma cataracts, double or blurred
vision, spots, specks, or flashing lights.
Ears: Denies hearing loss, tinnitus, vertigo, earache, infection, or drainage.
Nose: Affirms seasonal allergies in the spring and fall seasons to pollen and
goldenrod. Denies history of frequent colds, nasal congestion, epistaxis,
discharge, rhinorrhea, or postnasal drip or nasal itching. Denies sinus pain or
Throat: Denies dryness, sores and lesions on oral mucosa and tongue. Denies
dentures, bleeding gums, and missing, broken, or painful teeth. Last dental exam
3 months ago. Denies hoarseness, frequent sore throat, dysphagia, or halitosis.
Neck: Denies history of lumps, goiter, pain, and thyroid disease or neck masses. Denies
swollen glands or temperature intolerance.
Breasts: Denies history of lumps, pain, discomfort or discharge. Affirms she performs
preventative self-examinations monthly.
Respiratory: Denies history of cough, production of sputum, hemoptysis, dyspnea,
wheezing, pleurisy, bronchitis, emphysema, pneumonia, COVID, tuberculosis, or pain
with breathing. No previous chest x-ray. Childhood asthma, denies any history of
asthmatic symptoms in adulthood.
Cardiovascular: Denies history of high blood pressure, heart murmurs, palpitations,
chest pain or discomfort, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, syncope,
edema, rheumatic fever. Denies history of angina pectoris, atrial fibrillation, congestive
heart failure, myocardial infarction, dissecting aortic aneurysm, and pulmonary embolus.
No history of electrocardiogram, echocardiography, CT, stress tests, angiography, MRI or
Gastrointestinal: Denies dysphagia, odynophagia, dyspepsia, anorexia, nausea, retching,
regurgitation, or vomiting. Denies change in bowel pattern or function, color, size, or
caliber of stools. Denies history of diarrhea, constipation, tenderness, pain, anal itching,
tenderness of the rectum, tenesmus, cramping, bloating, food intolerances, straining with
defecation, mucus, exudate, melena, hematochezia, steatorrhea, or acholic stools, excess
flatus, anal intercourse, anal warts, hemorrhoids, or fissures. Bowel movements are
regular, formed, soft, light to dark brown, and occur usually once a day. Has never had
jaundice or hepatitis. Denies liver, gallbladder, or pancreatic trouble. No history of
Genital: Denies premenstrual tension, premenstrual syndrome, amenorrhea,
dysmenorrhea, polymenorrhea, oligomenorrhea, or menorrhagia. Onset of
menarche at age 14. Menses regular, every 28 days with moderate bleeding,
averaging six tampons daily. Menses last between 4-6 days. Last pap smear done
in January 2020, negative for intraepithelial lesion or malignancy; no HPV
detected. G0P000. Heterosexual orientation, age at first intercourse was 20.
Denies dysfunctional uterine bleeding, bleeding disorders, postcoital bleeding.
Denies history of endometriosis, adenomyosis, pelvic inflammatory disease,
cystocele, rectocele, endometrial and uterine polyps, and fibroids. Denies history
of polycystic ovarian syndrome and ovarian cysts. Denies vaginal discharge,
cervical or vaginal infections, or vaginal itching. Denies dyspareunia, vaginismus,
decreased libido or sexual dysfunction. Denies menopausal symptoms such as, hot
flashes, flushing, atrophic vaginitis, diaphoresis, insomnia or excessive
flatulence. Denies pelvic pain, pelvic floor dysfunction, sexually transmitted
diseases, HPV infection, multiple sexual partners, vulvar lesions, and anal
intercourse. Denies current pregnancy. Denies inguinal hernia..
Urinary: Denies history of urinary track infections, suprapubic pain, dysuria,
urgency, frequency of urination, polyuria, nocturia, incontinence, painful urination
or hematuria. No history of kidney infections or pain.
Peripheral vascular: Denies history of edema, numbness or tingling in extremities.
Denies history of varicose veins, DVT, or leg cramping. Denies history of color,
sensation or size changes in extremities.
Musculoskeletal: Denies low back pain, radiation of pain to lower extremities, buttocks,
or associate numbness, paresthesia, bladder or bowel dysfunction. Denies history of
cancer, pain at night or at rest, gout, history of intravenous drug use, pain lasting greater
than one month or unresponsive to treatment. Patient denies monoarticular or
polyarticular joint pain. Denies myalgias or arthralgias, or extra-articular pain. Denies
inflammatory joint pain, infectious joint pain, and decreased range of motion, stiffness, or
edema of joint. Denies tenderness, warmth, or redness of joint. Patient denies joint pain
with systemic symptoms such as fever, chills, anorexia, rash, weight loss, or weakness.
Denies joint pain related to other organ systems.
Psychiatric: No history of anhedonia, depression, nervousness, anxiety, PTSD,
nightmares, insomnia, hypersomnia, phobias, memory changes, or suicide attempts.
Neurologic: Denies changes in mood or attention or speech. Denies changes in
orientation or memory or insight or judgment. Denies headaches, dizziness, vertigo,
fainting, or blackouts. Denies any loss of consciousness, syncope or near-syncope. Denies
any generalized, proximal or distal weakness. Denies numbness, tingling, paresthesia,
paralysis, loss of sensation, tremors or involuntary movements or seizures.
Hematologic: Denies history of anemia or bruising or bleeding. Denies history of past
transfusions or reactions.
Endocrine: Denies history of polyuria, polydipsia, or polyphagia. Denies history of
heat/cold intolerance, weight changes, or excessive sweating. No history of diabetes or
General Survey: Patient is calm, demonstrates culturally-appropriate eye contact. Patient is
sitting comfortably and does not appear distressed despite elevated respiratory rate. She is alert
and oriented to person, place, and time; and is well-nourished and groomed wearing clothing
consistent with climate.
Vital Signs: Ht: 5 feet 4 inches, Wt: 125 lbs, BMI: 21.5, BP: 130/88 mmHg, HR: 100 bpm, RR:
22 breaths per minute, T: 101.5 degrees Fahrenheit, and denies pain.
Integument: Intact, ethnically appropriate fair color and complexion, warm, dry, smooth and
mobile. Turgor < 2 seconds. No suspicious moles, nevi, lesions, erythema, ecchymosis,
petechiae, jaundice or pallor.
Hair: Thick, shoulder-length, black, shiny and coarse hair. Well distributed and neatly
styled. Scalp clean. No signs of alopecia, excessive dandruff, nits or infestations.
Nails: Evenly trimmed, smooth and short with all nail plates intact. No signs of ingrown,
paronychia, infections, ridges, thickening, deformities, splitting, injury, clubbing or
Head: Skull is normocephalic, atraumatic, and symmetrical without deformities,
depressions, lumps, or tenderness. Facial expression is relaxed and calm. Features are
symmetrical. Face is without edema, involuntary movements, or masses.
Neck: Full range of motion of neck with flexion, extension, rotation, and lateral bending.
Anterior and posterior triangles of neck symmetrical bilaterally. Trachea midline. Thyroid
isthmus palpable. Thyroid gland smooth without masses, enlargement, or bruit. Thyroid
gland moves symmetrically upward with swallowing.
Lymph Nodes: Preauricular, posterior auricular, occipital, tonsillar, submandibular,
submental, superficial cervical, posterior cervical, deep cervical chain, and
supraclavicular lymph nodes non-palpable and non-tender bilaterally.
Eyes: Positioned and aligned symmetrically. Eyebrows move symmetrically without
scaliness or lesions. Palpebral fissure symmetrical. Upper and lower eyelids are well
approximated without ptosis, lid lag, or lesions. Eyelashes evenly distributed without
gaps. Medial and lateral canthus visualized without pain, redness, swelling or drainage.
Sclera white. Conjunctiva pink without exudate, nodules, or swelling bilaterally. Lacrimal
gland visualized bilaterally without redness, swelling, pain or drainage. Cornea and lens
without opacities bilaterally. Irises brown, flat, without crescentic shadow. Pupils round,
equal, and reactive to light and accommodation, 4 mm in size constricting to 2 mm in size
with light bilaterally. Bilateral vision 20/20 using Snellen chart. Extra-ocular movements
are full and coordinated without nystagmus. Confrontation by Static Finger Wiggle Test
full, without deficits. Positive red reflex. Fundus exam reveals reddish orange
background without hemorrhages, cotton wool spots, or Roth spots; optic disc margins
sharp, round and dark yellow. Optic cup is round and light yellow, cup to disc ratio 1:2;
arteries red, veins darker red without AV nicking emboli or infarcts, AV ratio 2:3; macula
not visualized, fovea lateral and slightly inferior to optic disc, darkened and circular. No
papilledema or virtuous floaters noted.
Ears: Pinna and skin around bilateral ears, face and scalp intact, without redness or
scaling, scars, masses, or lesions. Pinna, tragus, and mastoid process without tenderness.
Ear canal clear, without drainage, minimally occluded by soft yellow cerumen. Tympanic
membrane pearly gray, intact, mobile, without bulging or retractions. Malleus, umbo,
pars tensa and pars flaccida in appearance with cone of light visualized. Gross hearing
intact with whispered voice, 4/4 words correct. Weber without lateralization. Rinne
bilaterally AC>BC 2:1.
Nose: Midline and symmetrical to the face, tip non-tender to touch. Mucosa pink, without
inflammation, swelling or drainage. Septum midline, without perforations, no evidence of
epistaxis or crusting. Turbinates without edema, erythema, hypertrophy, lesions or
inflammation. Nasal airways patent. Non tender frontal and maxillary sinuses.
Mouth/Throat: No lesions, scaling or cracking on or around lips. Oral mucosa pink,
smooth, without ulcers, nodules, or white patches. Buccal membranes, hard palate, soft
palate pink, moist and intact. Tonsils grade 0. No halitosis. Gums pink and without
ulcerations or inflammation. 32 adult teeth without discoloration and intact. Tongue
symmetrical, moist, and without lesions, protrudes midline. Sublingual area without
nodules, ulcerations, white or reddened areas. Upper and lower frenulum midline and
intact. Soft palate rises with phonation. Moderate posterior pharyngitis without exudate
Thorax and Lungs: Nonlabored tachypnea of 22 breaths/minute. No cyanosis or clubbing.
Thorax symmetrical without deformities, impaired respiratory movements, or retractions. No use
of accessory muscles. No tenderness to pectoral muscles or costal cartilages. Chest expansion is
symmetrical AP: traverse ratio 1:2. No skin lesions, masses or tenderness noted. Symmetrical
lung expansion. Signs of consolidation shown with decreased tactile fremitus over the base of the
left lung along with dullness, egophony and discernable whispered sounds. Rhonchi heard upon
auscultation over base of left lung, right lung clear of adventitious sounds. Diaphragmatic
excursion 4 cm bilaterally. Breath sounds are vesicular throughout bilateral upper lobes, tracheal
breath sounds over the trachea and neck.
Cardiovascular: No jugular venous distention present. The jugular venous pulse is measured 3.5
cm above the sternal angle with the head of the bead elevated to 30 degrees; jugular venous
pressure is estimated at 8.5 cm. Carotids with bilaterally symmetric regular pulses without bruits.
Point of maximum impulse is tapping, palpable and identified visually approximately 2 cm in
diameter located at the left fifth intercostal space on the mid-clavicular line. No observable or
palpable heaves, lifts or thrills. Heart rate at 100 bpm with no audible clicks, murmurs, gallops or
rubs. Crisp S1 and S2 auscultated with S1 loudest at the apex and S2 loudest at the base and with
a physiologically split, with A2 > P2. No S3, S4.
Breasts and axillae: Symmetric. Skin has pink undertones and is smooth. No rashes, lesions.
Areola brown, no retraction of nipple. No deformities in shape when leaning over of flexing the
pectoralis. No tenderness or masses of breast or axillae. Axillary and inframammary lymph
nodes nonpalpable and nontender. No discharge from nipple.
Abdomen: The abdomen is free of scars, striae, dilated veins, rashes, or ecchymosis. The
umbilicus is midline, inverted and free of inflammation or excoriation. The abdomen is
symmetric and rounded with no visible organs or masses. There are no observable peristalsis or
pulsations. Bowel sounds are normoactive in all four quadrants with no bruits, venous hums, or
friction rubs. The aorta is two point five centimeters wide measured in the upper abdomen
slightly left of the midline. No thrills or bruits are noted at the aorta, renal artery, and iliac artery.
The abdomen is tympanic with scattered areas of dullness from fluid and feces. The liver is
approximately four centimeters at the midsternal line and six centimeters at the right
midclavicular line. The splenic percussion sign is negative. The abdomen is nontender with light
and deep palpation. There is a negative cough test and no guarding, rigidity, rebound tenderness,
or percussion tenderness. The liver is non-tender and the liver edge is soft, distinct, regular,
smooth, and is three centimeters below the right costal margin in the midclavicular line on deep
inspiration. The spleen is non-palpable. The kidneys are non-palpable and there is no
costovertebral angle tenderness. The bladder is non-palpable and there is no suprapubic
Genitalia: Hair is dark brown, coarse and evenly distributed over the mons pubis. No
infestations. Labial skin intact, without lesions, ulcerations or erythema. Urethral meatus is
without swelling or discharge. No enlargement, adhesions, or exudate of the clitoris, Skene’s or
Bartholin’s glands. Vaginal mucosa intact, pink, without inflammation, discharge, ulcerations, or
masses. Cervix round, smooth, pink and midline without lesions, bleeding or discharge. Pap
smear obtained. Uterus midline, anteverted with no enlargement, tenderness or masses. No
adnexal masses. Ovaries 1 cm in diameter, smooth and nontender. Pelvic floor muscles intact.
Rectal: No anal rashes, lumps, ulcers, inflammation, excoriation, internal or external
hemorrhoids, anal warts, perirectal lesions, or fissures. Rectal vault without masses, tenderness,
induration, irregularities, or nodules. Rectovaginal wall intact. Stool brown and hemocult
negative. External sphincter tone is a 3 on a scale of 0-5 on the DRESS scale.
Peripheral vascular and extremities: Warm to touch, no edema present bilaterally. Calves
supple, nontender upon palpation with flexion or extension. No varicosities in lower extremities.
No stasis pigmentation or formation of ulcers. Pulses palpable at +2.
Musculoskeletal: Face symmetrical, TMJ has smooth and full ROM, without redness, swelling,
snapping, clicking or tenderness. Masseters, temporal muscles, pterygoid muscles nontender.
Shoulders symmetrical without flattening or elevation, swelling, deformity, muscle atrophy,
abnormal positioning, or fasciculation. No bulge of subacromial bursa and no skin color change
or unusual bony contours. Subacromial and subdeltoid bursae, supraspinatus, infraspinatus, and
teres minor muscles demonstrate no tenderness or swelling. Full ROM via flexion, extension,
abduction, adduction, internal rotation, and external rotation of shoulder girdle without pain. No
displacement of olecranon process, tenderness, or effusion. Full ROM via flexion and extension
of elbow and full ROM via supination and pronation of forearm. Smooth and natural movements
of hands, fingers slightly flexed when relaxed and fingernail edges are parallel. No swelling,
tenderness, or bogginess over distal radioulnar joint, radiocarpal joint, intercarpal joints, distal
interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, or metacarpophalangeal
(MCP) joints. No deformities or angulation of wrists, hands, finger bones. Thenar and
hypothenar eminences full. No thickening of flexor tendons or flexion contractures of fingers.
Extensor and abductor tendons and snuffbox nontender. No nodules or bony enlargement of DIP
joints. Full ROM of wrists via flexion, extension, adduction, and abduction. Full, smooth and
coordinated ROM of fingers via flexion, extension, adduction, and abduction. Full ROM of
thumbs via flexion, extension, abduction, adduction, and opposition. Posture is upright and
symmetrical. Position of head, neck, and back are erect; with head midline in same plane as
sacrum. No spinal tenderness upon percussion. No increased thoracic kyphosis, scoliosis, or
unequal heights of iliac crests or shoulders, or pelvic tilt. No café-au-lait spots, birthmarks, portwine stains, hairy patches, lipomas, or bony defects of posterior spine. No paravertebral muscle
tenderness or spasm. Full ROM of neck via flexion, extension, rotation, and lateral bending. No
numbness, loss of sensation, tenderness, or weakness of neck or upper extremities. Full ROM of
spinal column via flexion, extension, rotation, and lateral bending without pain or tenderness.
Gait width is three inches from heel to heel. Gait is smooth, continuous rhythm, knee flexed
throughout stance phase and extended on heel strike. Leg length symmetric. No anterior or
posterior hip atrophy or bruising. No enlarged inguinal lymph nodes, bulges along inguinal
ligament, tenderness of groin, or sacroiliac joint tenderness. Ischiogluteal bursae not palpable, no
tenderness over trochanter. Full ROM of hips via flexion, extension, abduction, adduction,
external rotation, internal rotation. No atrophy of quadriceps muslces, no genu varum or genu
valgum. No swelling of patella, no knee pain or tenderness. No irregular bony ridges along
ribiofemoral joints. No medial or lateral collateral ligament tenderness. Patellar tendon intact,
without tenderness. Patella moves in smooth sliding motion. No thickening, tenderness,
bogginess, or warmth noted over suprapatellar pouch, prepatellar bursa, or anserine bursa.
Negative bulge, balloon, and balloting of the patella tests. No tenderness or swelling of
gastrocnemius o soleus muscles. No tenderness or thickening of Achilles tendon bilaterally. Full
ROM of knees via flexion, extension, internal rotation, and external rotation. Negative
McMurray test bilaterally, negative abduction and adduction tests bilaterally, negative anterior
and posterior drawer sign bilaterally, and negative Lachman test bilaterally. No deformities,
swelling, nodules, calluses, or corns of ankles or feet. No ankle joint swelling, bogginess, or
tenderness bilaterally. No nodules or tenderness of Achilles tendons. Posterior and inferior
calcaneus and plantar fascia nontender. Medial and lateral malleolus nontender. No tenderness on
compression of metatarsophalangeal joints bilaterally. No metatarsalgia. No forefoot
abnormalities. Full ROM of tibiotalar joints via flexion and extension without pain. Full ROM of
subtalar and transverse tarsal joints via inversion and eversion without pain.
Mental Status: Alert, relaxed and cooperative, thought process coherent; oriented to
person, place and time. Responds to questions appropriately.
Cranial Nerves: Cranial nerve I not tested; Cranial nerve II, III – visual acuity 20/20 right
eye, 2/20 left eye, 20/20 both eyes without correction; visual fields full; pupils round,
4mm in size, reactive to light and accommodation, constricting to 2mm; III, IV, VI –
extraocular movements intact, no nystagmus, no ptosis, no diplopia, no amblyopia; V
motor – temporal and masseter strength intact 5/5 bilaterally, no sensory facial loss noted
to sharp or dull sensation; corneal reflexes present; VII motor – bilateral facial
movements intact, no asymmetry noted, no abnormal movements; sensory – taste not
tested; VIII – hearing intact bilaterally to whispered voice; IX, X – voice is modulated,
not hoarse or nasally; no difficulty swallowing, rise and fall of soft palate symmetric,
uvula midline, posterior pharynx moves medially; gag intact; XI – strength of
sternomastoid and trapezius muscles 5/5; XII – clear articulation, no dysarthria; tongue
midline, no atrophy or fasciculation, no asymmetry or deviation.
Motor: Muscle bulk symmetric, proportionate to body, no atrophy noted. Muscle tone
intact with no evidence of decreased or increased resistance noted, equal bilaterally, no
marked floppiness or spasticity. Muscle strength 5/5 to upper and lower extremities,
bilaterally with flexion and extension, adduction and abduction Cerebellar – Rapid
alternating movements intact are coordinated bilaterally. Finger-to-nose and heel-to shin
performed. Smoothness and accuracy of movements noted bilaterally. Steady gait noted,
coordinated, balanced with steady base. Coordination with rhythmic movement and
steady posture noted. Romberg – balance maintained with eyes closed. No pronator drift.
Sensory: Sensation to pinprick and light touch over right and left face, arms and legs
intact bilaterally; position of bilateral big toes intact, position sense intact, no loss of
position sense; vibratory sensation demonstrated over distal interphalangeal joint of
bilateral fingers bilaterally without an loss or impairment; vibration intact over the
interphalangeal joint of big toes bilaterally without any loss or impairment.
Reflexes: Biceps, triceps, brachioradialis, patellar, ankle, and abdominal reflexes 2+ and
symmetric with plantar reflexes down going. soap note example -cough
Working diagnosis: Community Acquired Pneumonia (CAP). (ICD 10 Code J18.9).
Acute onset of symptoms such as productive cough with yellow-green and blood tinged
sputum, fever, shortness of breath upon exertion and increased respiratory rate could
indicate community-acquired pneumonia (Kaysin & Viera, 2016). Fever also indicates an
infectious cause. Physical assessment findings such as decreased tactile fremitus,
dullness, egophony and adventitious sounds in the lower left lobe indicate consolidation
which is a consistent finding in CAP (Kaysin & Viera, 2016). Ms. Chen’s history of
smoking puts her at a greater risk for contracting CAP.
1. Atypical CAP: (ICD 10 Code J18.9).While patients with this commonly present with
a dry “hacking cough,” this symptom is not exclusive and many patients have an
absence of pleuritic chest pain such as in Ms. Chen’s case (Centers for Disease
Control and Prevention [CDC], 2018). Patient’s with atypical CAP are also less likely
to have severe fatigue or symptoms affecting their daily activities and can more
closely resemble symptoms of a common chest cold (CDC, 2018). Atypical CAP
commonly has a prodrome of viral symptoms similar to influenza such as rhinitis,
sore throat or headache (Oda et al., 2018).
2. Acute Bronchitis: (ICD 10 Code J20.9). Patients with acute bronchitis usually present
with the predominant symptoms being a productive or nonproductive cough that is
usually self-limiting and lasts less than three weeks but greater than five days (Smith
et al., 2020). While it is unlikely a fever will persist for greater than a few days after
onset, bronchitis symptoms usually follow an upper respiratory infection (Kinkade &
Long, 2016). Since Ms. Chen did report some symptoms consistent with an upper
respiratory infection last week, it is still within a reasonable time frame to suspect a
fever could persist that is consistent with acute bronchitis. While physical
examination findings of lung consolidation typically indicate pneumonia over acute
bronchitis, if pneumonia is eliminated as a diagnosis these symptoms could be
consistent with bronchitis as well (Kinkade & Long, 2016).
3. Influenza: (ICD 10 Code A15.0). Influenza symptoms have an acute onset including
cough, nasal congestion, sore throat and myalgia. These symptoms are usually selflimiting but can develop respiratory complications such as bronchitis or pneumonia if
a patient presents with positive respiratory physical examination findings
(Ghebrehewet et al., 2016). With Ms. Chen initially reporting mild symptoms that
then progressed to the productive cough, influenza needs to be determined or ruled
out as a causative agent for her illness in order to progress treatment.
4. Pulmonary Tuberculosis: Ms. Chen’s symptoms of blood-tinged sputum, fever,
persistent cough and travel outside of the country within the past six months raise
suspicion for pulmonary tuberculosis from Mycobacterium bacterium. While
hemoptysis is usually a late symptom in the disease showing cavitation, blood tinged
sputum accompanied with fever, cough, night sweats, weight loss or chills may be
early symptoms (Loddenkemper et al., 2016). While some patients may present as
asymptomatic, patients experiencing respiratory symptoms may have positive
examination findings consistent with consolidation in the lungs (Loddenkemper et al.,
1. Oxygen Saturation: To determine presence of hypoxia if oxygen saturation is less
than 90% which can determine the patient’s ability to continue treatment on an
outpatient basis (Bates, n.d.).
2. Chest X-ray: This is the gold standard for diagnosis of pneumonia. A chest x-ray can
determine pneumonia compared to other possible diagnoses such as tuberculosis,
bronchitis or cardiovascular etiologies. While a chest x-ray cannot identify specific
pathogens causing pneumonia, it may show focal infiltrates with pleural effusion to
suggest bacterial infection or interstitial infiltrates which suggest viral infection.
Tuberculosis can be seen on a chest x-ray with cavities without air-fluid levels (Bates,
3. Complete blood count with differential and metabolic profile: This can indicate
elevated white blood cell (WBC), neutrophil and lymphocyte count. These levels can
guide pharmacologic interventions by indicating viral or bacterial origin.
Additionally, a metabolic profile will show carbon dioxide levels, renal and liver
function which can influence antibiotic therapies (Kaysin & Viara, 2016).
4. Sputum culture and gram stain: May be helpful in determining bacterial pathogens in
severely ill patients (Bates, n.d.).
5. Influenza test: Can determine if symptoms are attributed by influenza A or B.
6. Blood Cultures and Urine Antigen Tests: These are recommended for patients with
severe pneumonia to determine the presence of legionella and pneumococcal antigens
Bates’ Visual Guide to Physical Examination (Producer). (n.d.). Objective structured clinical
examinations (OSCE): Cough
. Wolters Kluwer.
Centers for Disease Control and Prevention (CDC). (2018). Mycoplasma pneumoniae infections.
Ghebrehewet, S., MacPherson, P., & Ho, A. (2016). Influenza. BMJ, 355, i6258.
Kaysin, A. & Viera, A. J. (2016). Community-acquired pneumonia in adults: diagnosis and
management. American Family Physician, 94(9), 698-706.
Kinkade, S. & Long, N.A. (2016). Acute Bronchitis. American Family Physician, 94(7), 560-
Loddenkemper, R., Lipman, M., & Zumla, A. (2016). Clinical Aspects of Adult
Tuberculosis. Cold Spring Harbor perspectives in medicine, 6(1), a017848.
Ota, K., Iida, R., Ota, K., Sakaue, M., Taniguchi, K., Tomioka, M., Nitta, M., & Takasu, A.
(2018). An atypical case of atypical pneumonia. Journal of general and family
medicine, 19(4), 133–135. https://doi.org/10.1002/jgf2.179
Smith, M.P., Lown, M., Singh, S., Ireland, B., Hill, A. T., Linder, J.A., & Irwin, R. S. (2020).
Acute cough due to acute bronchitis in immunocompetent adult outpatients. Chest
Journal, 157(5), 1256- 1265. https://doi.org/10.1016/j.chest.2020.01.044
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. Page 1
BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 5: Cough
This video format is designed to help you prepare for objective structured clinical examinations, or
OSCEs. soap note example -cough
So Ms. Chen, tell me what is your average weight that you keep.
You are going to observe and participate in a clinical encounter of a 45‐year‐old woman who comes to
the office with a complaint of a cough. As you observe the encounter, you will be asked to answer
questions while the image on the screen freezes. These questions will allow you to practice the skills of
history taking and physical examination skills as well clinical reasoning as you develop your assessment
or differential diagnosis, and plan—that is, an appropriate next diagnostic workup.
You will have time to record your findings and receive feedback.
Ms. Chen, tell me your special concerns.
I have been coughing for a week and just can’t seem to stop. I can hardly sleep at night.
Have you been bringing up any phlegm or sputum?
I’ve been coughing up a yellow‐green mucus, sometimes with pink streaks that seem to be blood.
What diagnoses are you considering at this time?
How much pink streaking are you seeing at any one time?
Just a tinge, but maybe 3 or 4 times a day.
Have you had any fevers or chills?
Yes, I checked my temperature yesterday and it was 101°F.
What about shortness of breath?
I do feel shortness of breath when I’m working outside, but not when I’m working at my desk.
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Have you noticed any wheezing?
Just once in a while when I’m going up the stairs fast, or when I’m doing heavy work in the yard.
Have you had any of these symptoms before, or had any asthma?
No, not since I was a kid. I did have some mild asthma when I was in elementary school but luckily I
never had to go the hospital.
Any pain in your chest when you take a deep breath?
No, no pain when I breathe in or out.
You mentioned that you’re coughing a lot at night. Are you using any extra pillows?
Well, the last few nights I have been using two pillows instead of one. It seems to help me clear my
Have you had any acid taste, or reflux?
No, not really.
How about any recent colds?
Well, actually last week I came down with a runny nose and a sore throat, but then my symptoms got
Have you had any sinus congestion?
Well, my sinuses do feel full a lot. Um…I first feel a drip in the back of my throat, um…but now the worst
thing is the cough.
What about allergies when you’re outside?
Pollen and golden rod get me every spring and fall. Right now my spring allergies are almost over.
And what do you do for those?
Antihistamines usually help. Um…I do try to cut down on my smoking, but right now my symptoms now
are much worse than usual, especially with the bad cough and phlegm.
Do you have pets at home? soap note example -cough
Yes, we have two cats. I’ll admit right now that they sleep in our bedroom.
Well, animal fur picks up allergens, you may want to consider having them sleep in a different part of
the house, or even outside.
Can you tell me if you still smoke cigarettes?
I’ve smoked two packs a day for the last 10 years. I’ve tried to stop but I work as a dispute mediator.
With all that stress I just can’t seem to quit.
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Have you had any weight loss or night sweats?
No, my weight is fine, and no night sweats.
Has anyone around you been ill? Or have you been exposed to tuberculosis?
My family and co‐workers are fine. When I was a kid though, my grandmother told me she had
tuberculosis in her 20s.
Have you been checked for tuberculosis, with a skin test like a tine test or PPD?
I did have one of those PPDs about 10 years ago when I started my current job, and it was negative.
Have you had a chest x‐ray?
No, I’ve never had a chest x‐ray.
What about any recent travel? Have you been out of the country?
Well, I did go to Shanghai a few months ago to visit my cousins…um, however this cough is much more
recent. No other travel.
I’d like to go back to the pink streaks in your sputum that you mentioned. Are you taking any
medications right now, such as aspirin or ibuprofen?
Right now I’m taking a decongestant over the counter and some ibuprofen maybe twice a day or so. I’m
not on any regular medication.
Okay, let’s talk about your general health. Do you drink alcohol?
Well, a glass of wine, 3 times a week.
Have you ever used any oral, nasal, or injection drugs such as marijuana, cocaine, amphetamines, or
No, never, even though I know people who do.
To be thorough, given your cough, I need to ask about your sexual activity. What is your sexual
preference, men, women, or both?
Now, just a few questions about your past health…I see you are 45. Have you ever had any problems
with your heart or lungs?
No, I’m still able to work out even with the smoking. I just had that asthma a few times when I was in
How about any surgery?
No, no surgery. I’ve never even been to the hospital.
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Okay, is there anything else that you would like me to know?
No, I think you’ve covered everything.
Okay, let’s start your physical examination.
With the patient’s health history in mind, and after good hand hygiene, you are ready for the physical
Okay, your temperature is up a little at 101.5°F. Your blood pressure is 130 over 88. Your heart rate is
100 and you’re breathing at about 22 breaths a minute, which is higher than normal.
What regions of the physical examination are important in this patient?
Head and neck, heart and lungs, extremities.
Okay, first I’d like to check your head and neck.
Examine the ears.
Palpate the sinuses.
Examine the throat and mouth.
Palpate the anterior and posterior cervical lymph nodes.
Okay, your ears look fine but your throat is a little red, otherwise it’s okay. Now I’d like to check your
Percuss the lungs.
There is some dullness here over the base of your left lung. Can you say “99” for me a few times?
Palpate for tactile fremitus.
Auscultate the lungs.
[RALES AND RHONCHI SOUNDS]
Can you say “99” for me a few times?
Listen for bronchophony, or louder transmitted voice sounds, which are abnormal.
Good, now can you whisper the number “99”?
Listen for whispered pectoriloquy, or louder whispered sounds, which are abnormal.
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Okay. Can you say the letter “E” for me 2 or 3 times?
Listen for egophony, or “E to A” changes, which are abnormal.
Okay, you can stop.
How am I doing?
I’m hearing some changes from consolidation in your left lower lung. Let’s continue the examination and
then we can talk more. Can you lie back for me?
Auscultate the anterior chest.
Check the neck veins for jugular venous pressure.
Palpate the carotid upstroke…
…and listen for bruits.
Listen to the heart in the six positions.
Listen to the abdomen.
Palpate the abdomen.
Inspect and palpate the calves and ankles for tenderness and swelling.
List your diagnostic considerations in order of importance and explain your rationale.
Press pause and list your answers. Resume when you are ready to receive feedback.
Community acquired pneumonia: This 45‐year old smoker has a productive cough, mild shortness of
breath, and fever. On physical examination she has an elevated temperature and a mildly elevated
respiratory rate and dullness, increased tactile fremitus, rhonchi, and E to A changes in the left lower
lobe of her lungs, all features suspicious for the lung consolidation of community‐acquired pneumonia.
Rapid onset of symptoms and pleuritic chest pain are also characteristic, and 25‐50% of patients have an
accompanying pleural effusion. Risk factors include COPD, cardiovascular disease, diabetes, and
Atypical community‐acquired pneumonia: Atypical pneumonia frequently presents with a persisting
non‐productive “dry hacking cough,” low‐grade fever, and absence of pleuritic chest pain. Lung
examination findings are variable, but may be normal. Clinical features do not clearly distinguish atypical
from typical pneumonias. This patient’s symptoms, especially fever, productive cough, and positive lung
findings, make this diagnosis less likely.
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Bronchitis: In acute bronchitis, which is usually self‐limiting, cough typically follows an upper respiratory
infection and persists for more than 5 days. Sputum production is variable and may be blood‐tinged.
The chest examination is normal. In chronic bronchitis look for chronic cough with sputum, often seen in
smokers. Unlike this patient, chronic cough lasts for more than 8 weeks. Note that symptoms and
findings suggesting sinus infection or GERD are minimal.
Pulmonary tuberculosis: This patient’s blood‐tinged sputum raises the possibility of pulmonary
tuberculosis from Mycobacterium tuberculosis; however, in tuberculosis cough is usually present for
more than 2 to 3 weeks and hemoptysis is usually a late symptom reflecting cavitation. Actual sputum
may not be present. Initially patients are often asymptomatic then progress to constitutional symptoms
such as weight loss, anorexia, fatigue, fever, chills, night sweats, and cough. The lung examination may
be normal except for crackles, or rales.
Lung cancer: Lung cancer is unlikely in this patient due to the acute onset of cough with productive
sputum, fever, and confirming lung examination findings. However, the possibility arises since this
patient is a smoker with a cough and blood‐tinged sputum though not hemoptysis. Lung cancer
symptoms usually appear late, including cough, hemoptysis, chest pain, and dyspnea but symptoms also
arise from metastatic spread. Cigarette smoking causes roughly 90% of lung cancers.
List 5 next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready to receive feedback.
O2 saturation: In an office setting, pulse oximetry helps identify hypoxia when the oxygen saturation
falls below 90%, particularly in smokers and patients with COPD or known lung disease. It is important to
note that the oxygen saturation can be high even when the more important indicator of oxygenation,
the pO2, is considerably lower due to the S‐shape of the oxyhemoglobin dissociation curve. In more
seriously ill patients an arterial blood gas is indicated.
Chest x‐ray: Chest x‐ ray is the gold standard for diagnosis of pneumonia. Although it does not identify
the causative pathogen, focal infiltrates with pleural effusion suggest bacterial infection. Interstitial
infiltrates are common in mycoplasma, chlamydia, and viral infection. Cavitation with air‐fluid levels is
suspicious for abscesses from staphylococci, anaerobes, or gram negative bacilli. Cavities without air‐
fluid levels are seen in tuberculosis and fungal infection. Chest x‐ray also helps identify cough related to
heart failure, COPD, and malignancy soap note example -cough
Complete blood count with differential and metabolic profile: These standard tests identify the rise in
white blood cell count and neutrophils, elevation of CO2, anemia, and renal and liver disease that
influence antibiotic therapy.
Sputum culture and gram stain: Collecting a sputum culture and gram stain before starting therapy is
controversial, but can help guide therapy in severely ill patients.
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Blood cultures: Blood cultures and urine testing for legionella and pneumococcal antigens are
recommended for patients with severe pneumonia.
In sum, the patient is a 45‐year‐old dispute mediator with cough productive of yellow‐green and
occasional blood‐tinged sputum for a week, fever, mild shortness of breath and occasional wheezing,
and a 10‐year history of smoking 2 packs of cigarettes a day. There is a remote history of travel and TB
exposure, which do not contribute to the current clinical presentation. On examination her temperature
is 101.5°F; blood pressure, 130 over 88; heart rate, 100; and respiratory rate, 22. She has dullness,
decreased breath sounds, and egophony in the left lower lobe.
Diagnostic considerations include Community‐acquired pneumonia, which is most likely, atypical
community‐acquired pneumonia, acute bronchitis, pulmonary tuberculosis, and lung cancer.
The diagnostic workup includes O2 saturation, chest x‐ray, CBCd and metabolic profile, sputum culture
and gram stain, and blood cultures.
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