SOAP Note Format for COPD
S – Subjective
Chief Complaint: “I’ve been experiencing shortness of breath and a persistent cough for several months.”
History of Present Illness:
60-year-old Hispanic female presents with progressive dyspnea, chronic productive cough, and occasional wheezing.
Symptoms worsen with exertion and during cold weather.
Reports fatigue and difficulty sleeping due to coughing.
Denies chest pain or hemoptysis.
Smoked one pack per day for 30 years; quit 5 years ago.
No known allergies.
Past Medical History:
Hypertension
Hyperlipidemia
Former smoker
No history of asthma or tuberculosis
Family History:
Father had COPD
Mother has diabetes
Social History:
Retired school teacher
Lives with husband
Limited physical activity due to breathlessness
No alcohol or drug use
Review of Systems:
Respiratory: Chronic cough, dyspnea, wheezing
Cardiovascular: No chest pain or palpitations
GI: No nausea or vomiting
Neuro: No dizziness or headaches
O – Objective
Vital Signs:
BP: 138/86 mmHg
HR: 88 bpm
RR: 22 breaths/min
Temp: 98.6°F
SpO₂: 92% on room air
Physical Exam:
General: Alert, cooperative, mild respiratory distress
Lungs: Decreased breath sounds bilaterally, expiratory wheezes, prolonged expiration
Heart: Regular rate and rhythm, no murmurs
Extremities: No edema or cyanosis
Diagnostic Tests:
Chest X-ray: Hyperinflated lungs, flattened diaphragm
Spirometry: FEV₁/FVC ratio 80% B. FEV₁/FVC ratio < 70% C. Increased FVC D. Normal FEV₁ Answer: B
4. Which medication is used as a short-acting bronchodilator in COPD? A. Tiotropium B. Fluticasone C. Albuterol D. Prednisone Answer: C
5. What is the purpose of pulmonary rehabilitation in COPD management? A. Cure the disease B. Improve lung function C. Enhance quality of life and exercise tolerance D. Replace medication Answer: C
6. Which vaccine is recommended annually for COPD patients? A. Hepatitis B B. Influenza C. MMR D. Varicella Answer: B
7. What is a common physical exam finding in COPD? A. Crackles B. Dull percussion C. Expiratory wheezes D. Bronchial breath sounds Answer: C
8. What is the significance of a flattened diaphragm on chest X-ray? A. Pneumonia B. Pleural effusion C. Hyperinflation in COPD D. Atelectasis Answer: C
9. What is the recommended oxygen saturation threshold for initiating oxygen therapy in COPD? A. < 95% B. < 92% C. < 90% D. < 88% Answer: D
10. Which of the following is a long-acting bronchodilator? A. Albuterol B. Tiotropium C. Prednisone D. Montelukast Answer: B
11. What lifestyle modification is most critical for COPD patients? A. Weight loss B. Smoking cessation C. Alcohol reduction D. Increased caffeine intake Answer: B
12. Which ethnic and age group does the patient in the SOAP note belong to? A. Hispanic male, 45 years old B. Hispanic female, 60 years old C. Caucasian female, 70 years old D. African American male, 55 years old Answer: B
13. What is the role of inhaled corticosteroids in COPD? A. Cure the disease B. Reduce inflammation and exacerbations C. Increase oxygen levels D. Replace bronchodilators Answer: B
14. Which of the following is NOT a symptom commonly associated with COPD? A. Chronic cough B. Dyspnea C. Hemoptysis D. Wheezing Answer: C
15. What is the recommended follow-up interval after initiating COPD treatment? A. 1 week B. 2 weeks C. 4 weeks D. 6 months Answer: C