SOAP Note on Asthma
United State University
Primary Healthcare of Chronic Client/Families Across the Lifespan-Clinical Practicum
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.
CC: “I have been experiencing recurrent coughing, shortness of breath, wheezing, and chest tightness.”
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 used any 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.
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
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.
Occupation: Retired teacher
Illicit drugs: Denies
Living situation: She lives in a safe residential estate apartment with her son’s family, her son has three children. No pets.
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 records
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 loss or 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, or excessive 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.
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, abnormal vaginal discharge, blood in the urine or pain with urination
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.
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.
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. No exudate, lesions, inflammation
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 slightly inspiratory 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.
Psychiatric: Cooperative, alert, good mood, and behavior. Clear response. Oriented, judgement appropriate, mood and effect appropriate, and normal memory.
· Complete blood count reveals normal results
· peak expiratory flow rate (PEFR): 65%
· FEV1/FVC ratio: predicted 74%
1. Asthma (ICD-10 code J45. 909) – is an inflammation and constriction of the airways (King et al., 2018). The result is increased mucous production, which causes coughs and wheezing (King et al., 2018). Most people who develop Asthma do so during their childhood. However, anyone of any age can develop Asthma (Pakkasela et al., 2020). Adults in their 60s and 80s are not uncommon to experience their first asthma symptoms (Pakkasela et al., 2020). When Asthma develops later in life, the symptoms are very similar to those of anyone else. The most common triggers of an asthma attack are a respiratory illness or viral infection, workout, allergens, or exposure to pollutants in the air (Pakkasela et al., 2020). In this case, the patient reported tightness in the chest, coughing, and wheezing, which are asthma symptoms. The patient also reported that she noted the symptoms after she visited the zoo. Having an asthmatic family member also increases the risk significantly (Pakkasela et al., 2020). In this case, it is more likely that the condition will be diagnosed because Asthma is in the family history. Laboratory tests confirmed the diagnosis of Asthma.
2. Common variable immunodeficiency (ICD-10 code D83.8) – This is an immune system disorder caused by a genetic mutation (Aggarwal et al., 2022). Individuals with this disorder have minimal levels of antibodies in the blood. Infections may become more frequent in people whose bodies do not produce enough antibodies to fight them off (Aggarwal et al., 2022). One may experience symptoms such as cough, shortness of breath, and recurrent sinus infections (Aggarwal et al., 2022). Based on patient signs and symptoms, she is not experiencing any sinopulmonary infections, this rule out common variable immunodeficiency. Further diagnostic testing could be done to rule out sinopulmonary infection like serum IgG level<500 mg/dl. 3. Pulmonary embolism (ICD-10 code I26. 9) –is a condition that manifests when a blood clot blocks an artery in the lungs (Lambrini et al., 2018). This will block blood flow in the lungs which can be a life-threatening condition. Symptoms may include shortness of breath, fever, cough, chest pain, leg swelling, and skin discoloration (Lambrini et al., 2018). The diagnosis was ruled out since the patient did not report some of the mentioned symptoms, like pleuritic chest pain, fever, lower extremity edema, or skin discoloration. Further diagnostic test could be done to rule out pulmonary embolism like D-dimer measurement and CT pulmonary angiography. 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