SOAP Notes FOR Asthma - soap note PDF

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Running head: SOAP NOTES FOR ASTHMA

SOAP Notes for Asthma Name Institutional affiliation Due date

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2 SOAP NOTES FOR ASTHMA SOAP Notes for Asthma SUBJECTIVE DATA Name: Kylie Jenner Hospital: Galaxy Medicare Center Initials: K.J

Date: 11/20/2019

Address: 1425 Houston Drive, NY, House No.38533 Birthdate: 8/28/1974 Age: 45 Sex: F, Race: African American, Marital status: married Next of kin: Husband (Timothy) Employer: Businesswoman, she owns a boutique Ward: Emergency department, acute room Chief complaint “I have been coughing, feeling my chest to be tight when I breath, producing sounds when breathing for the past 3 days. I get tired easily when doing tasks, which affects my breathing rate. I sweat sometimes. The symptoms are severe in the morning and evening”. History of presenting illness Kylie Jenner is a 45-year-old female, who presented with the following symptoms on admission. Gradual onset of cough, a week ago. 3 days ago, she experienced chest tightness, wheezing, dyspnea on exertion and coughing which gets worse in the morning and at night. The location of the symptoms is the chest and lungs. The patient reported taking some

3 SOAP NOTES FOR ASTHMA Chlorphenamine and acetaminophen to alleviate the symptoms. The symptoms are aggravated by being in the cold and doing a lot of work. Past medical and surgical history She reports a history of hospitalization, due to asthma 2 years ago, in the same hospital. No history of childhood illness, no history of surgery, no history of blood transfusion. She does not have a drug or food allergy, she has been taking asthma drugs but stopped 6 months ago. She received all immunizations. Family history She is a 3rd born in a family of 4; both siblings are alive and well. She is married with 3 children all are well and alive. Husband is suffering from diabetes and on routine care in this hospital. Her parents are deceased, father due to asthma, mother due to a car accident where she died on the spot. Grandparents are all dead, all due to old age. Socio-economic history She is a businesswoman. She has a health socio relationship with family and friends. She does not abuse substances. She is a Christian. She gets support from friends and family. Review of systems Head: head grows evenly, black. She reports no headache and no migraine. Ears and eyes. She reports good eyesight and hearing, no abnormality Nose: she reports stuffiness when breathing. Neck: No swollen glands

4 SOAP NOTES FOR ASTHMA Respiratory system. She reports coughing, chest tightness, and wheezing Cardiovascular system: she reports chest pain and dyspnea. Musculoskeletal: No joint stiffness, pain nor weakness Endocrine: she reports some sweating Genitourinary: no discharge, no bloody urine Genital reproductive. Started her menarche at 13, she has had 3 full-term pregnancies; she is not on family planning method since her husband has done a vasectomy. OBJECTIVE Height: 1.5 m Weight: 140 lbs. BMI: 22 Temp: 98.8 (oral) HR: 74 RR: 16 BP: 120/78 Physical examination. Inspection Generally, Client in distress, on oxygen. Patient alert, oriented to time place and person. No abnormality detected. The patient has peripheral cyanosis. Auscultation: S1 and S2 sound heard, no crackles, wheezes present. No heart murmurs. Bowel sounds present Palpation: no tenderness on the abdomen. No swelling Percussion. Resonance on the chest and abdomen. All the other body systems are doing well. Investigations

5 SOAP NOTES FOR ASTHMA Monitor vital signs 2 hourly, carry out sputum and blood test to check for signs of T.B and any infection, measure oxygen saturation levels by pulse oximetry, measure ABGs, and Pulmonary function tests. ASSESSMENT Diagnosis: Acute Asthma Exacerbation due to wheezing or sudden onset. Differential diagnosis. Acute respiratory tract infection due to elevated temperatures, fever, perhaps bacterial infection. The asthma episode may have resulted because of her abandoning her medications, thinking that the disease was cured. PLAN Obtain family, environment, and occupational history to rule out what must have caused the symptoms. Pharmacological management Nebulize with Albuterol 5mg once. Give promethazine 6.25 -15 mg to decrease inflammation, QID. Give Zyrtec 10 mg daily. Beclomethasone 200 mg BD, prednisone 30 mg TDS. Acetaminophen for fevers. Broad-spectrum antibiotic if blood culture is positive for bacteria.Hospitalization if symptoms persist, mechanical ventilation if the respiratory system fails. Continuously assess airway and treatment response. Monitor blood pressure and cardiac rhythm closely. Give IV fluids in case of dehydration. Fluid intake by mouth to loosen any

6 SOAP NOTES FOR ASTHMA secretion hence facilitates expectoration. Make sure the room is free of respiratory irritants such as smoke, perfumes, flowers and odours. Advice on adequate rest.

7 SOAP NOTES FOR ASTHMA References Domino, F. J. (Ed.). (2010). The 5-minute clinical consult 2011. Lippincott Williams & Wilkins. Codina Leik, M.T (2014).Family nurse practitioner certification intensive review (2nd ed.) ISBN 978-0-8261-3424-0....