Case Study Assessment on Cough with soap note

If productive, one should ask about the colour, viscosity, and the amount. Essentially normal sputum is light and white whereas sputum associated with pathology is purulent, greenish-yellow with blood tinge. This is significant as will play a major role in coming up with differential diagnosis. Associated factors: The patient should be asked about any other condition associated with the chief complain. These factors could include; chest tightness and pain, hemoptysis, shortness of breath, fever, night sweats, easy fatigability, chills, and arthralgia. Chronic illnesses like TB should also be inquired about. Immunization history: As if the patient received immunizations in this case pneumococcal vaccine is significant Review of systems Cardiovascular: Ask about orthopnea, claudication, high blood pressure, palpitations ankle swelling, exercise intolerance Gastrointestinal: Enquire about nausea, vomiting, diarrhea, constipation and distension Respiratory: purulent cough, wheezing, dyspne...