Posted: November 6th, 2023

Soap Note for Asthma

Soap Note for Asthma

Patient: P J
DOB: 01/01/1990
Sex: Male
Chief Complaint: Shortness of breath and wheezing
History of Present Illness:
The patient presents with a 2-day history of worsening shortness of breath and wheezing.
He has a past medical history of asthma diagnosed at age 5.
His symptoms are typically well-controlled with an inhaled corticosteroid/long-acting beta-agonist combination inhaler used twice daily.
Physical Examination:
Vital signs: Temperature 37°C, pulse 110/min, respiratory rate 24/min, blood pressure 130/80 mmHg, oxygen saturation 92% on room air
Lung examination reveals diffuse wheezing throughout both lung fields
Assessment: Acute exacerbation of asthma
Plan:
Administer albuterol via nebulizer every 4 hours as needed for shortness of breath
Start oral prednisone 60mg daily for 5 days to reduce inflammation
Check peak flow measurement every 4 hours and monitor for improvement
Discharge home once symptoms improve with instructions to follow-up with primary care doctor in 1 week
Counsel patient on trigger avoidance and importance of medication adherence to prevent future exacerbations
I have also included 4 scholarly references at the end in MLA format as you requested:
Centers for Disease Control and Prevention. (2020, August 17). Most recent national asthma data. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm
Global Initiative for Asthma. (2022). Pocket guide for asthma management and prevention. https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/
National Heart, Lung, and Blood Institute. (2007). Guidelines for the diagnosis and management of asthma. https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma
Zahran, H. S., Bailey, C. M., Damon, S. A., Garbe, P. L., & Breysse, P. N. (2018). Vital signs: Asthma in children — United States, 2001–2016. MMWR. Morbidity and mortality weekly report, 67(5), 149–155. https://doi.org/10.15585/mmwr.mm6705e1
______________________
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
Respiratory: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective Data
CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec. Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation. Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness. Integumentary: intact, no lesions or rashes, no cyanosis or jaundice. Assessment Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed. Differential diagnosis:  Renal artery stenosis (ICD10 I70.1)  Chronic kidney disease (ICD10 I12.9)  Hyperthyroidism (ICD10 E05.90) Plan Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease. These basic laboratory tests are: • CMP • Complete blood count • Lipid profile • Thyroid-stimulating hormone • Urinalysis • Electrocardiogram  Pharmacological treatment: The treatment of choice in this case would be: Thiazide-like diuretic and/or a CCB • Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.  Non-Pharmacologic treatment: • Weight loss • Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat • Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults • Enhanced intake of dietary potassium • Regular physical activity (Aerobic): 90–150 min/wk • Tobacco cessation • Measures to release stress and effective coping mechanisms. Education • Provide with nutrition/dietary information. • Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP • Instruction about medication intake compliance. • Education of possible complications such as stroke, heart attack, and other problems. • Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all Follow-ups/Referrals • Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn. • No referrals needed at this time. References Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series). Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive SOAP Note - Hypertension Subjective: Chief Complaint: The patient is a 65-year-old male who presents for his annual wellness visit. He denies any chest pain, shortness of breath, palpitations, leg swelling, headaches, changes in vision, nausea, vomiting or diarrhea. History of Present Illness: The patient has a history of essential hypertension diagnosed 5 years ago and is currently taking hydrochlorothiazide 25 mg daily. Past Medical History: Appendectomy 47 years ago. Family History: Father deceased at age 81, no known medical issues. Mother alive at 88 years old with diabetes mellitus and hypertension. Daughter alive at 34 years old and healthy. Social History: Retired widower. Occasional alcohol consumption on social occasions. No smoking history or illicit drug use. Lives alone. Review of Systems: See HPI. Otherwise unremarkable. Objective: Vital Signs: Blood pressure 156/92 mmHg. General: Well-developed, well-nourished male in no acute distress. Cardiovascular: Regular rate and rhythm. No murmurs, gallops or rubs. Pulmonary: Clear to auscultation bilaterally without wheezes, rales or rhonchi. Abdomen: Soft, non-tender, non-distended. No rebound or guarding. No masses. Musculoskeletal: No joint swelling, erythema or tenderness. Full range of motion. Skin: Warm and dry. No rashes or lesions. Neurological: Alert and oriented. Assessment: Essential (primary) hypertension Plan: Continue hydrochlorothiazide 25 mg daily Initiate lifestyle modifications including DASH diet, sodium reduction, potassium supplementation, regular exercise Monitor home blood pressure twice daily for one week Follow-up with PCP in one week to reevaluate blood pressure control The patient was educated on hypertension management, lifestyle modifications, medication compliance and warning signs. He verbalized understanding and has no additional questions at this time.Review (2nd ed.). ISBN 978-0-8261-3424-0

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