Asthma SOAP Note - soap note PDF

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S.O.A.P. Note Template Case ID#: 005 Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan)

Basic Information Patient demographics Krona VienteNueva DOB 11/1/1990 Insurance: Aetna

Subjective History Chief Complaint A 36-year-old female presents with twenty-four hour history of urinary frequency and burning with urination. The patient reports that she feels as if she is no completely emptying her bladder, and that she has a some pelvic pain which rates as a 3/10 at its worst.

History of Present Illness Pt. reports that she is sexually active, and has one partner. The patient uses contraceptives and states that she always uses a condom. She currently has had no vaginal discharge, and no history of urinary incontinence. The patient denies using scented soap and denies fever. The patient further denies blood in urine and states that her last menstrual period started on March 3, 2020.

Past Medical History The patient denies any pertinent illnesses as a child. Pt. states that she does not have frequent urinary tract or yeast infections. However, she did have her tonsils out at the age of 8. The patient notes that she was diagnosed as having Asthma at age 10, and had only one hospitalization at age 11. The

patient reports that she received her flu vaccine this year, and has no upper respiratory infections, or environmental allergies. The ony medication the patient currently takes for her asthma is albuterol.

Family History Mother: Healthy with no current health condition. Father: HTN, Asthma Siblings: Asthma.

Personal/Social History Education: Currently attending University. Marital status: Single Occupation: Student, Works at Zoo alcohol/drug use: Pt. denies alcohol Use and also denies recreational drug use. Smoking status: Pt. denies smoking history Sexual history: Heterosexual Exercise: Occasionally when she has time. Nutrition: Tries to eat a healthy diet.

Review of Systems (as applicable to CC)                

General: no weight loss, fever, chills, sweats, anorexia, fatigue or malaise. Hair, Skin, & Nails: No rashes, lesions, itching, dryness, sweating, Head: No headache, hair trauma or hair loss. Neck: Supple, no lumps, no lymphadenopathy, trachea midline Eyes: No glasses, eye discomfort, eye discharge, photophobia. Ears: No ear ache, ear discharge, vertigo, hearing changes, tinnitus Nose: No congestion, epitaxis. Mouth & Throat: No sore throat, hoarseness, dysphagia or odynophagia. Cardiovascular: No chest discomfort, palpitations syncope or edema Respiratory: Chest tightness, wheezing and shortness of breath. Breasts: Deferred Gastrointestinal: Denies any discomfort, change in bowel habits. Musculoskeletal: Deferred Peripheral: Deferred Neurological: Deferred Psychiatric: No depression, suicidal ideation, memory loss, mental disturbances, hallucinations, anxiety or paranoia. Alert and appropriately dressed.

Physical Examination   

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(as applicable to CC/HPI)

Vital signs: T 98.8; BP 130/88; R 24; HR 114; O2 97%; Wgt 110 General Appearance: Pt. is a plesant 22 year old female appropriately dressed in no acute distress who reports SOB, chest tightness, and wheezing for three days. HEENT:normocephalic and atramautic. Hair average texture. Sclera while, conjunctiva pink; PERRLA; Funduscopic, disc margins sharp, no hemorrhages or exudates. TM clear with cone of light. Nasal mucosa pink nasal septum midline, sinus nontender. Oral mucosa pink without lesions, Pharynx without exudates, tongue midline. Neck: Trachea midline, neck supple, thyroid isthmus palpable, lobes not felt. Lymph Nodes: Cervical lymph nodes, non-tender, Epitrochlear lymphnodes, nontender and non palpable. Chest: Wheezes heard bilaterally, Cardiac: JVO nonelevated, no visable heaves. Chest nontender. S1, S2 no murmurs or bruits noted. Abdomen: Abdominal presents with normal contour, no scars, striae, or varicosities. Bowel sounds +4, no bruits noted. Soft on palpation, nontender no masses felt. No CVA tenderness of kidneys. Spleen nontender, nonpalpable, liver nontender, size WNL. Genitourinary: Skin: Color consistent with ethnicity, warm and dry, no rashes, or lesions. Nails no clubbing or cyanosis. Musculoskeletal: Deferred Neurologic: Deferred Psychiatric: AO x4 no anxiety, suicidal ideation, depression, mental disturbances.

Diagnostic Testing/Findings

(if appropriate)

Spirometry: 75% FEV1

Assessment 

Primary diagnosis: Asthma Exacerbation

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Differential Diagnosis:  Bronchiectasis – is a lung disease which presents in parts of the airways which

have enlarged due to lung damage (Science Daily, 2019). Patients with this diease process find it challenging to cough up phlegm and are more prone to viral, bacterial and/or fungal infections. Patients with this diease process tend to have higher allergic rates to dust mites, and fungi (Science Daily, 2019). The patient does not have the symptoms which would definitively associate her with bronchiectasis which include Coughing up yellow or green mucus every day

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Shortness of breath that gets worse during exacerbations

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Feeling run-down or tired, especially during exacerbations

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Fevers and/or chills, usually developing during exacerbations

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Wheezing or a whistling sound while you breathe

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Coughing up blood or mucus mixed with blood, a condition called hemoptysis (American Lung Association, 2019).

Bronchitis o The signs and symptoms of bronchitis include cough, production of mucus which can be clear or white, yellowish-gray or green, fatuigue, shortness of breath fever and chills (National Heart, Lung, and Blood Institute, 2019). The patient does not present with any of these symptoms except shortness of breath.

Plan/Education 1. Administer albuterol 1/25 mg/3ml via nebulizer solution in office setting and reexamine. 2. Renew Albuterol inhaler 90 mcg per actuation take 2 puffs q 4 – 6 hours as needed for quick relief. 3. Qvar Redihaler 40 mcg/actuation take two puffs q 12 hours BID. 4. One adult spacer 5. Education on how to use the spacer when administering albuterol and Qvar. Wash face after use of spacer, and rinse mouth. 6. Return to office if there is no improvement within 48 hours. 7. Avoid triggers such as animal hair, dust, mold, pollen or other allergens.

References American Lung Association (2019). Bronchiectasis symptoms, causes & risk factors. Retrieved From: https://www.lung.org/lung-health-and-diseases/lung-diseaselookup/bronchiectasis/symptoms-causes-risk-factors.html National Heart, Lung, and Blood Institute (2019) Bronchitis. Retrieved from: https://webcache.googleusercontent.com/search?q=cache:THm8KFGkHsJ:https://www.nhlbi.nih.gov/healthtopics/bronchitis+&cd=20&hl=en&ct=clnk&gl=us

Science Daily (2019) Lung disease bronchiectasis associated with high frequency allergy. Retrieved from: https://www.sciencedaily.com/releases/2019/04/190404094852.htm...