SOAP NOTE essay paper
SOAP NOTE
SOAP Note on Asthma
Name xxxx
United State University
Primary Healthcare of Chronic Client/Families Across the Lifespan-Clinical PracticumSOAP NOTE
xxx
Professor xxxxxx
Date xxxxx
SOAP Note on Asthma
ID: Initials A.C, Age 66, Sex female, Race: African American,DOB 1/1/1956. Marital status: Widow. Patient seems to be a good historian.
SUBJECTIVE:
CC: “I have been experiencing recurrent coughing, shortness of breath, wheezing, and chest tightness.”SOAP NOTE
HPI: A.C., A 66-year-old African American female who visits the clinic after experiencing symptoms of wheezing, coughing, chest tightness but denies chest pain, and shortness of breath, which have gotten worse at night when lying flat. She notes that her symptoms aggravated after she visited the zoo three weeks ago. The patient reports experiencing symptoms approximately three times a week and once a day. She stated to have not usedany medication to alleviate the symptoms. The patient has a past medical history of Asthma, which she had at the age of 15 and was treated with Albuterol inhaler 90 mcg every 4 hours as needed. She denies other major illnesses. She denies fever, nausea, or vomiting. No fatigue. She has no seasonal allergies.SOAP NOTE
PMH: History of Asthma treated with Albuterol inhaler 90 mcg every 4 hours as needed but stated, she has not used any medication since the past 2 years.
Allergies: No known allergy
Surgical: None
Medications: Not taking any medication currently.
Immunizations: Received all recommended vaccinations, including 2 doses of Pfizer-BioNTech COVID-19 vaccine and 1 booster shot. Last flu shot given 10/10/2021.
Social HistorySOAP NOTE
Occupation: Retired teacher
Tobacco: Denies
Illicit drugs: Denies
Caffeine: Denies
Alcohol: Denies
Exercises: Denies
Diet: Vegan
Living situation: She lives in a safe residential estate apartment with her son’s family, her son has three children. No pets.
Family History:
Husband died at age 70 in a road accident.
Mother died at age 88, had history of Asthma.
Father – Died in a military war.
Brother – Alive and has a history of Asthma.
Paternal grandfather – Diseased with unknown medical recordsSOAP NOTE
Paternal grandmother – Diseased with unknown medical records
Maternal grandfather – Diseased with unknown medical records
Maternal grandmother – Diseased with unknown medical records
Review of Systems
General: Denies any unexplained fatigue, unwanted weight lossor gain, night sweats, muscle pain, fever, or chills.
Head: Denies loss of consciousness or head injuries.
Eyes: Denies blurred vision or floaters, eye pain, irritation, orexcessive tears. Uses corrective lenses.
Ears: Denies difficulty hearing, ringing in ears, discharge, or ear pain.
Nose: Denies nosebleed, loss of smell, nasal congestion, or pain.
Mouth/Throat: Denies bleeding gums, or lesions. Denies sore throat, swallowing discomforts, altered taste, or hoarseness.SOAP NOTE
Skin: Denies skin color change, bruises, rashes, or lesions.
Cardiovascular: Reported episodes of chest tightness on a recurrent basis. Denies irregular and rapid heart rate,tachycardia, or palpitations.
Respiratory: Reports coughing, shortness of breath, wheezing,and chest tightness.
Gastrointestinal: Denies nausea, vomiting, constipation,abdominal discomforts, diarrhea, or blood in the stool. She reports regular bowl movement 2x a day.
Genitourinary: Denies urine frequency, urgency, abnormalvaginal discharge, blood in the urine or pain with urinationSOAP NOTE
Musculoskeletal: Denies experiencing muscle pain, rigidity, edema, or any other pain.
Breast: Denies masses, tenderness, or breast lumps. Last mammogram was 6 months ago.
Heme/Lymph/Endo: Denies history of blood transfusion, swollen gland, or excessive sweating.
Neurologic: Denies seizures, dizziness, headaches, syncope, or tremors.
Psychological: Denies depression, suicidal thoughts, memory loss, hallucinations, or anxiety.
OBJECTIVE:
Physical Exam
Temp: 98.4F BP: 126/77mmHg Pulse: 85 beats per minute Resp: 20
Height: 5’ 6” Weight: 151lbs BMI: 24.3 kg/m2
General Appearance: The patient appears to be healthy and well-nourished, but she seems to be in slight distress. Her attire is clean and appropriate for weather. Awake and alert, oriented to place, time and reason for her visit.SOAP NOTE
Skin: Smooth, warm, and dry. No rashes, bruises, or change in skin color.
Head: normocephalic, and symmetric
Eyes: EOMI. Anicteric. PERRLA eyes. No allergic shiners, conjunctiva is pink.
Ears: Hearing grossly intact, external auditory canals and tympanic membranes pearly gray. Cone of light at 5:00right and 7:00 left.
Nose: Moist mucous membranes. Nasal mucosa pink. No bleeding, lesions. No pain in the frontal and maxillary sinuses.
Mouth/Throat: lips, tongue, buccal mucosa, soft palate, anterior and posterior pillars are intact. Pharynx normal. Noexudate, lesions, inflammationSOAP NOTE
Neck: Non-tender cervical area, trachea is in the midline, non-enlarged thyroid palpated.
Gastrointestinal: Non-tender, soft, and non-distended abdomen. No palpable masses. Normal active bowel sound all four quadrants.
Respiratory: Apparent nonproductive cough and slightlyinspiratory wheezing heard in the bilateral upper lope. No rhonchi, or crackles.
Cardiovascular: Regular heart rhythm with S1 and S2 sounds.No murmur.
Musculoskeletal: No swollen, or tender joints or muscles. No difficulty bending or moving her arms and legs. No misalignment, or tenderness. Full range of motion, normal stability, strength and tone, and normal gait.
Neurological: Normal gait and Stable balance. Clear speech and clear voice tone. Normal to touch, pinprick, and vibration, deep tendon reflexes 2 + 4 and symmetrical.SOAP NOTE
Psychiatric: Cooperative, alert, good mood, and behavior. Clear response. Oriented, judgement appropriate, mood and effect appropriate, and normal memory.
ASSESSMENT:
Lab tests:
Differential DDX:
Primary Diagnosis: Asthma (ICD-10 code J45. 909)
PLAN:
Chest X-ray: to rule out other lung pathology like pneumonia, bronchitis, and pneumothorax.
Treatment: Low dose inhaled corticosteroid plus short-acting beta agonist as needed like
Fluticasone propionate inhaled 44 mcg per actuation; Inhaled 2 puffs (44 mcg per activation) twice a day.
Albuterol inhaler 90 mcg per actuation; Inhaled 2 puff every 4hrs as needed for asthma.
Patient Education: The patient is educated on the importance of medication adherence.
She is informed to ensure that there is avoidance of dust to prevent triggering the asthma attack, advised to have adequate sleep, and moderately engage in regular exercise and maintenance of healthy body weight.
Follow-up: The patient was informed to visit the clinic if symptoms worsen or if any serious adverse effects occur.
Referrals: Patient referred to an allergist to assist in the identification of environmental triggers.
References
Aggarwal, V., Banday, A. Z., Jindal, A. K., Das, J., & Rawat, A. (2020). Recent advances in elucidating the genetics of common variable immunodeficiency. Genes & diseases, 7(1), 26-37. https://doi.org/10.1016/j.gendis.2019.10.002
Amin, S., Soliman, M., McIvor, A., Cave, A., & Cabrera, C. (2020). Understanding patient perspectives on medication adherence in Asthma: a targeted review of qualitative studies. Patient preference and adherence, 14, 541.https://doi.org/10.2147/PPA.S234651
Haahtela, T., Jantunen, J., Saarinen, K., Tommila, E., Valovirta, E., Vasankari, T., & Mäkelä, M. J. (2022). Managing the allergy & asthma epidemic in 2020s‒lessons from the Finnish experience. Allergy.https://doi.org/10.1111/all.15266
King, G. G., James, A., Harkness, L., & Wark, P. A. (2018). Pathophysiology of severe Asthma: We‘ve only just started. Respirology, 23(3), 262-271.https://doi.org/10.1111/resp.13251
Lambrini, K., Konstantinos, K., Christos, I., Petros, O., & Areti, T. (2018). Pulmonary embolism: A literature review. Am J Nurs Sci, 7, 57-61.
Pakkasela, J., Ilmarinen, P., Honkamäki, J., Tuomisto, L. E., Andersén, H., Piirilä, P., … & Lehtimäki, L. (2020). Age-specific incidence of allergic and non-allergic asthma. BMC pulmonary medicine, 20(1), 1-9. https://doi.org/10.1186/s12890-019-1040-2
