Soap Notes Asthma Coursework Example

Soap Notes: Asthma
Student’s Name
Institutional Affiliation
Soap Note: Asthma
Patients Initials……………… Age…………………… Gender………………………
(S) Subjective data
Chief Complaint (CC): Wheezing, Chest tightness, shortness of breath and Chest Pains
History of Present Illness (HPI)
Mary Paul is a 35yr old Hispanic female who has a past medical history of asthmatic attacks. Currently, she states that the asthma attacks have been occurring after every two hours since yesterday as she was on a team-building trip with her colleagues. The patient has complained of Wheezing, chest pains, shortness of breath and chest tightness. She also states the attack she experienced had no distinguishing features and it was similar to her prior ailments. The patient has complained of having a high fever (98.7) over the past days, extreme tiredness, and she has experienced yellowish-greenish nasal secretions. The last asthmatic attack she suffered was four months ago, and it was not severe. Conversely, Mary Paul has not been hospitalized over the past couple of years due to any Asthma attacks, although she states that she was intubated for asthma ten years ago. Currently, the patient has not been using her Albuterol and Flovent inhalers for the past couple of days. She has denied any coughs, sore throat, trauma, sinusitis symptoms, and cardiovascular attack. Mary Paul states that she has exacerbation when she tries to work out and mostly during fall due to weather changes. However, she explained that the severity of the symptoms decrease after she uses her inhaler and takes a long rest.

She checked in today for a medical checkup since the symptoms have increased, making her experience difficulties while breathing.
Current medications:
Flovent HFA
Albuterol MDI
Mucinex 1-2 tab PO PRN bronchial secretions.
Allergies: No known allergies to Medications or foods.
Past Medical History (PMH):
Asthma
Seasonal Allergies
Hypertension.
Past Surgical History (PSH)
Cesarean Section 2000
Reproductive History
Heterosexual
Normal Menstruation
Social History: Mary Paul denied any past use of tobacco or illegal drugs, although she stated that she consumes alcohol socially.
Immunization History: All the patient’s immunizations are up-to-date
Family History: Father had Asthma and Hypertension
Lifestyle:
The patient is an Real Estate Consultant, a mother to one son, and divorced for over 6 years now. She resides in her own home located in a calm neighborhood with improved infrastructure. Based on her job position and monthly earnings, she is financially stable. She attends medical checkup on a monthly basis due to her asthma attacks and she maintains a healthy balanced diet.
Review of Systems
General: Mary Paul reported Chest tightness, wheezing, shortness of breath and Chest Pains, but she denied weight loss, skin dryness, blurred vision, sinusitis, cough and ulcerations.
HEENT: The patient reported increased chest tightness over the past couple of days, a decreased sense of smell due to nasal congestion, secretion of yellowish-greenish nasal secretions as depicted in the HPI. However, she denied nausea, vomiting, hearing problems, change in vision, nose bleeding, diarrhea, rash and loss of consciousness and coordination.
Neck: Patient denied any injuries or pains on the neck.
Breasts: Normal Breasts, and no reported pains.
Respiratory: No coughs, but patient complained of chest tightness and chest pains.
CV: The patient denied an increase in blood pressure, irregular heartbeats and extreme swelling due to temperature variation.
GI: there were no issues of Nausea, Vomiting, heartburn, diarrhea or abdominal discomfort.
GU: No changes in Urinary frequency, denied pains while passing urine, regularity in the menstrual cycle (29-30 days), denied ovulation cramping and breast changes.
MS: Patient denied any muscular aches in the arms and legs, no joint swelling or arthritis issues.
Neuro: No issues of seizures, lack of concentration, anxiety or imbalances.
Psycho: Patient denied changes in her moods, depression or stress.
Lymph: Patient has a normal skin and she denied any itching or bleeding complications over the past years.
Endocrine: Patient showed no signs of endocrine symptoms.
Allergies: No known allergies to medications or foods.
(O) Objective Data
Physical Observation
General: The patient is a well-groomed 35yr old Hispanic female, who exemplifies no acute distress but appears ill. She is alert, oriented and cooperative.
Vital Signs: Temperature 99.2, Pulse 72, Respirations 22, Blood Pressure 120/80, Height 5’6, Weight 128 lbs., BMI 2O.5.
HEENT: The patient’s pupils are equal and reactive to light, the extra ocular eye movements are intact. The ear’s bilateral canals are patent and non-tender with no edema or lesion. The bilateral tympanic membranes are intact. The Nose has bilateral nares congested with yellow-greenish secretions. The throat has posterior oropharynx erythematous although there is no tonsillar edema. The mucous membranes are pink and moist with no signs of ulceration.
Neck: The neck is supple with no signs of lymphadenopathy.
Chest: The thorax is symmetric and non-tender. Expiratory wheeze noticed across the lung fields. Diminished breath sounds.
Cardiovascular: Patient’s heart rate is regular with no gallops, rubs or murmurs.
Abdomen: The patient’s abdomen is soft with no rebounds and guarding.
Extremities: Patient had no extremity edema issues. The peripheral pulses are equal in all four extremities.
Assessment
Lab Tests and Results
Diagnostic
Chest x-ray indicated no severe cardiopulmonary disease. The lung fields were clear, and there were no infiltrates present.
Differential Diagnoses: Foreign nasal obstruction, Bronchitis, Pneumonia, allergic bronchopulmonary aspergillosis (ABPA), pneumothorax and Influenza.
Possible Diagnosis/ Client’s problems
1: Acute Asthma Exacerbation
Acute Asthma Exacerbation in adults is usually characterized by cases of wheezing, chest tightness, chest pains and shortness of breath. These Exacerbations are propelled by weather changes, respiratory viruses and allergens in environments (Hyland Et al. 2015). In the examination, the significant findings include increased pulse and respiratory rates, and auscultations of lung sounds. Notably, the administration of bronchodilators will minimize the obstruction of airflow and prevent future reoccurrence. Delayed treatment could result in complications such as pneumonia, respiratory failure, and in some severe cases death.
2. Respiratory Tract Infection
Respiratory Tract Infection would have occurred due to viral and allergic causes. This diagnosis is characterized by the nasal congestion and the production of the yellow-greenish nasal secretion, fever, sinusitis pressure, asthmatic history, exposure to tobacco smoke and environmental allergens (Rava Et al. 2017).
3. Acute Bacterial Sinusitis
Acute sinusitis results in the inflation of the sinusitis, and it is a common diagnosis in this case. It is characterized by fever, chest pains due to upper respiratory infection, and chest tightness. In cases where the signs and symptoms of acute sinusitis prolong for more than ten days, it is termed as bacterial etiology (Hyland Et al. 2015).
The Primary Diagnosis was likely to be Asthma due to the increased rate of respiration, wheezing on auscultation, augmented chest pains and tightness.
(P) Plan
Management: Start patient on the Albuterol metered inhaler two puffs 15 minutes, and a refill of her Albuterol and Flovent Prescription for Asthma before any vigorous activity. Acetaminophen 500-1000mg Q 6 hrs for fever administered orally. Antibiotic issued is a daily dose Azithromycin Pack 500mg and then 250mg PO for four days. For shortness of breath and chest tightness, ProAir HFA 2 puffs Q 4-6 hrs.
Education: The patient was enlightened on the importance of acquiring primary care including a clinic list, and she was also provided with an albuterol metered-dose inhaler. She was advised to visit the hospital often for evaluation during the beginning of the Asthma exacerbation to mitigate the risks of the difficulties. The patient was counseled on the symptoms which would require medical attention. The patient was advised on the use of the Peak Flow Meter and encouraged to use it at home and record readings.
Follow Up: the patient was advised to visit the hospital after one week for further checkups.
Reflection
In similar patient evaluation program, there are various aspects that I would change. Notably, the patient Asthma symptoms and treatment of exacerbation was discussed with the patients. Fatal complications of acute asthma were also reviewed to exemplify the importance of early medical intervention. This education was necessary since the patient had delayed seeking medical treatment. Unfortunately, during the visit, the patient was not notified of how to maintain an asthma action plan. According to my opinion, I would change this aspect since it is a great measure to reinforce the importance of determining early signs of asthma exacerbation to hinder delay of treatment situation for the patient. I would also refer the patients to an ENT and Allergies specialist to broaden the patient’s choice of therapeutic options which is vital for managing allergic asthma and minimizing acute exacerbation.

Students Signature Date

Preceptor SignatureDate
References
Hyland, M., Whalley, B., Jones, R., & Masoli, M. (2015). A qualitative study of the impact of severe asthma and its treatment showing that treatment burden is neglected in existing asthma assessment scales. Quality Of Life Research, 24(3), 631-639.
Rava, M., Ahmed, I., Kogevinas, M., Moual, N. L., Bouzigon, E., Curjuric, I., & … Nadif, R. (2017). Genes Interacting with Occupational Exposures to Low Molecular Weight Agents and Irritants on Adult-Onset Asthma in Three European Studies. Environmental Health Perspectives, 125(2), 207-214.
Youngwirth, J. (2016). “SOAP” Notes for Advisers? Journal of Financial Planning, 29(2), 20-21.