SOAP_Note_Asthma.docx.pdf

Running head: SOAPNOTE ON ASTHMA 1

Soap note on Asthma

Name: H.C Date: 06/11/20Sex: Female Age: 14SUBJECTIVE DATAHistorian:

Mother and child

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SOAPNOTE ON ASTHMA 2

CC:

“My child has been having recurrent episodes of chest tightness, coughing, wheezes and

shortness of breath.”Child profile:

Child has experienced breast development and has started her menstrual periods. She has also

been showing more concern with her weight and appearance. She recognizes her own

strengths and weaknesses and has been showing increased independence.Child has also been

setting personal goals and has been spending most time with her peers.

Child is a Freshman and is in grade 9.

No developmental issues are reported.PHM:

A 14 years old Hispanic girl visits the office accompanied by her mother. She report that she

has been having recurrent episodes of chest tightness, coughing, wheezes and shortness of

breath and that the symptoms have been worsening at night and when she is engaged in

physical activities. Patient says that she experiences symptoms about three times a week and

once a day. She adds that the symptoms also worsen during cold days and seasons and when

she is in a dusty environment. To alleviate symptoms, patient says that she keeps warm and

tries to avoid physical activities though she enjoys being in the netball team in school. Patient

adds that when she experiences the symptoms especially shortness of breath and wheezes, she

has to stop what she is doing and rest for her symptoms to get better before she can continue

with her activities. She is having wheezes and has to take a break to continue with her speech.

She says that dust and cold affects her because she coughs a lot and experiences wheezes when

she is exposed to cold and dust. Mother says that patient is currently under no medication and

was diagnosed with pneumonia when she was 5 years old but was treated. She also says that

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SOAPNOTE ON ASTHMA 3

the patient’s father has asthma. Medication: None.Past Medical History:

Chronic and other ailments: Pneumonia when patient was 5 years old.

Immunizations: Received Influenza vaccines in September 2019.

Hospitalization and surgeries: Hospitalized when she was 5 years old because of pneumonia.

Allergies: Patient experiences shortness of breath and wheezes when she is exposed to dust

and cold.Family History: Father has asthma and mother and siblings have no known chronic disorders. Social History: Patient is a freshman and is in grade 9. She lives with her parents in an

apartment in town and her mother says that they stay in a safe neighborhood. Her parents take

alcohol occasionally but her mother denies smoking and drug abuse. Patient also denies

alcohol, smoking and drug abuse. Patient enjoys spending her weekends with her peers and

her family. ROSGeneral: Denies general feeling of tiredness

and sickness, fever, night sweats, chills and

sudden change in weight.

Cardiovascular: Reports recurrent episodes of

chest tightness and denies fast and irregular

heart rate, palpitations and chest pain. Respiratory: Reports recurrent episodes of

chest tightness, coughing, wheezes and

shortness of breath.

Gastrointestinal: denies stomach acidity,

upper abdominal pain, eating disorders,

constipation, and nausea, diarrhea and

abdominal distension. Musculoskeletal: Reports chest tightness and

denies muscle aches, upper and side back

pains, and joint pain and swelling.

Psychiatric: Mother says that patient spends

most of her nights up. Denies depression,

suicidal thoughts and attempts, excess worry

and anxiety.HEENT: Denies eye discharge and pain, nasal

congestion and mucus, sore throat and

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SOAPNOTE ON ASTHMA 4

swallowing difficulties. Denies hearing loss

and ear pain and irritation. Heme/Lymph/Endo: Reports intolerance to

cold and denies intolerance to heat, changes

in energy levels, sudden changes in weight,

swollen glands, bruising, and blood transfer.

Neurological: Patient reports that she has to

take breaths to talk. She denies headaches,

transient paralysis, syncope, and fainting.

OBJECTIVEVital signs Weight: 150 lb

BMI:25.12

Temp: 98.5 BP: 117/73

Height:64.8 in Resp: 26 Pulse: 85General Appearance: Patient looks well-built and nourished but she is in mild distress. He

dressing is smart and appropriate.Skin: Skin has no scales, sores, lesions, discoloration, changes in moles, dry skin and wounds.Respiratory: Wheezes are present and respirations are difficult. Lungs are clear bilaterally. HEENT: Scalp and hair have no abnormalities, neck is supple and thyroid glands are intact,

tympanic membrane is not inflamed, nasal inflammation and septal deviation are absent, throat

and oral mucosa are pink with no sores and neck has no lumps and thyroid glands are not

swollen. Cardiovascular: S1 and S2 are normal and heart rhythm and rate are regular. Capillaries refill

in 2 seconds and pulse is normal throughout. Gastrointestinal: Abdomen is not distended and masses are absent. Bowel sounds are absent

and tenderness and guarding are absent. Musculoskeletal: Patient bends and moves upper and lower extremities with ease. No swollen,

stiff and tender joints and muscles are observed. Neurological: Cranial nerves are intact, motor responses are normal and reflexes are normal. Psychiatric: Patient is attentive and is oriented. She responds to questions appropriately and

her speech is clear with tone of normal rate and cadence. Pediatric/Adolescent Assessment Tools: Deferred.Lab tests:

FEV1/FVC ratio: 73% of predicted.

FEV1: 76% of predicted.

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SOAPNOTE ON ASTHMA 5

peak expiratory flow rate (PEFR): Low.

CBC: Normal.

CXR: Normal.Diagnosis and treatmentDifferential Diagnosis

D83.8 Common variable immunodeficiency: This is an antibody deficiency that reduces the

body’s immune system ability to defend itself against bacteria and viruses. This causes

recurrent and severe infections in the respiratory tract, ears and sinuses. It presents through

signs such as ear infection, recurring lung infections, breathing problems, diarrhea, weight

loss, frequent sinus infections and chronic coughs. Patient stated that she has been having

some of these symptoms but did not report sinopulmonary, infections making the diagnosis

less likely and lab tests disqualified the diagnosis.

I50.9 Congestive heart failure: This is a progressive chronic disorder in which fluid

accumulates in the heart causing inefficient pumping of the heart (Francis & Tang, 2019). It

presents through signs such as fatigue and weakness, shortness of breath, persistent wheezing

and cough with mucus, intolerance to exercises, swelling of extremities and irregular or fast

heart rate. Patient stated that she has some of these symptoms but did not report a history of

uncontrolled HTN or CAD which are common in CHF hence making the diagnosis less likely.

I26.09 Pulmonary embolism: This occurs when an artery in the lungs is blocked by a

substance from any other part of the body. It presents through fever, dizziness, discolored skin,

irregular or fast heart beat, shortness of breath, chest pains and coughs. Patient did not report

some of these symptoms and lab test results disqualified the diagnosis.

Primary Diagnosis:

J45.909 Asthma: This is a respiratory disorder which occur when airways swell and narrow

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SOAPNOTE ON ASTHMA 6

resulting in excess production of mucus. This result in coughing and wheezing which the

patient reported (Lambrecht, Hammad&Fahy, 2019). Asthma also repents through chest

tightness which patient also reported and one of tits risk factors is having a blood relative with

asthma which the patient reported making the diagnosis most likely. Lab tests results

confirmed asthma as the primary diagnosis.

Treatment Plan:

Further testing: None.

Medication: fluticasone inhaled (FloventDiskus) 100 mcg inhaled PO q12hr; not to exceed

500 mcg q12hr (Jentzsch, Silva, Mendes, Brand &Camargos, 2019).

Education: Patient was instructed on how to use the medication and advised to avoid triggers,

cover mouth when it is cold, maintain a healthy weigh, have ample sleep and have moderate

regular exercises (Meltzer et al., 2020).

Follow up: If symptoms aggravate or incase of any severe side effects. References

Francis, G. S., & Tang, W. W. (2019). Pathophysiology of congestive heart failure. Reviews in

cardiovascular medicine, 4(S2), 14-20.

Jentzsch, N. S., Silva, G. C., Mendes, G., Brand, P. L., &Camargos, P. (2019). Treatment

adherence and level of control in moderate persistent asthma in children and

adolescents treated with fluticasone and salmeterol. Jornal de pediatria, 95(1), 69-75.

Lambrecht, B. N., Hammad, H., &Fahy, J. V. (2019). The cytokines of

asthma. Immunity, 50(4), 975-991.

Meltzer, L. J., Beebe, D. W., Jump, S., Flewelling, K., Sundström, D., White, M., … & Strand,

M. J. (2020). Impact of sleep opportunity on asthma outcomes in adolescents. Sleep

medicine, 65, 134-141.

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SOAPNOTE ON ASTHMA 7

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