Posted: March 18th, 2023

SOAP Note #3 Main Diagnosis: Asthma

Soap Note # ____ Main Diagnosis ______________ PATIENT INFORMATION Name: Age: Gender at Birth: Gender Identity: Source: Allergies: Current Medications: • PMH: Immunizations: Preventive Care: Surgical History: Family History: Social History: Sexual Orientation: Nutrition History:

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Subjective Data: Chief Complaint: Symptom analysis/HPI: The patient is … Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. ) CONSTITUTIONAL: NEUROLOGIC: HEENT: RESPIRATORY: CARDIOVASCULAR: GASTROINTESTINAL: GENITOURINARY: MUSCULOSKELETAL: SKIN: Objective Data: VITAL SIGNS: GENERAL APPREARANCE: NEUROLOGIC: HEENT: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: MUSKULOSKELETAL: INTEGUMENTARY:

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ASSESSMENT: (In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data) Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.) Main Diagnosis (Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 7th Edition. Differential diagnosis (minimum 4) - - PLAN: Labs and Diagnostic Test to be ordered (if applicable) • - • - Pharmacological treatment: - Non-Pharmacologic treatment: Education (provide the most relevant ones tailored to your patient) Follow-ups/Referrals References (in APA Style) Discussion Topic: Soap Note 3 "ASTHMA" _________________________ SOAP Note #3 Main Diagnosis: Asthma

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PATIENT INFORMATION Name: John Smith Age: 28 Gender at Birth: Male Gender Identity: Male Source: Self-referred Allergies: None Current Medications: None PMH: Childhood asthma, allergic rhinitis Immunizations: Up to date Preventive Care: Annual physical exam Surgical History: None Family History: Mother has asthma Social History: Non-smoker, occasional alcohol use, works as a software engineer Sexual Orientation: Heterosexual Nutrition History: Balanced diet, no specific restrictions Subjective Data: Chief Complaint: Shortness of breath and wheezing Symptom analysis/HPI: The patient reports experiencing difficulty breathing with wheezing and coughing for the past week. The symptoms are worse at night and during exercise. The patient reports no fever, chills, or chest pain. The patient has a history of childhood asthma, and the symptoms are similar to what he experienced in the past. Review of Systems (ROS) (Pt states….. ) CONSTITUTIONAL: No weight loss, no fatigue, no malaise NEUROLOGIC: No headaches, no seizures, no dizziness HEENT: No sinus pain, no nasal congestion, no ear pain, no sore throat RESPIRATORY: Shortness of breath, wheezing, coughing CARDIOVASCULAR: No chest pain, no palpitations, no edema GASTROINTESTINAL: No nausea, no vomiting, no abdominal pain GENITOURINARY: No dysuria, no hematuria, no frequency MUSCULOSKELETAL: No joint pain, no muscle pain SKIN: No rash, no itching, no hives Objective Data: VITAL SIGNS: Blood pressure 120/80 mmHg, pulse 80 beats per minute, respiratory rate 24 breaths per minute, oxygen saturation 93% on room air GENERAL APPREARANCE: The patient appears to be in moderate respiratory distress, sitting upright and using accessory muscles to breathe NEUROLOGIC: Alert and oriented, no focal neurological deficits HEENT: No nasal congestion or discharge, no pharyngeal erythema or exudate, no tonsillar enlargement, normal tympanic membranes, no cervical lymphadenopathy CARDIOVASCULAR: Regular rhythm, no murmurs, rubs, or gallops, no jugular venous distension RESPIRATORY: Diffuse expiratory wheezes heard bilaterally, decreased breath sounds at the bases, prolonged expiratory phase GASTROINTESTINAL: Soft and non-tender abdomen, no hepatosplenomegaly MUSKULOSKELETAL: No deformities, no tenderness INTEGUMENTARY: Warm and dry, no rash or lesions ASSESSMENT: The patient presents with symptoms consistent with an asthma exacerbation, including shortness of breath, wheezing, and coughing. The patient has a history of childhood asthma and reports similar symptoms in the past. Physical examination reveals moderate respiratory distress, diffuse expiratory wheezes, and decreased breath sounds at the bases. The patient's oxygen saturation is low at 93% on room air.

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Main Diagnosis: Asthma, ICD10 code J45.909 (American Psychiatric Association, 2013) Differential diagnosis: Chronic obstructive pulmonary disease (COPD) Bronchitis Pneumonia Pulmonary embolism PLAN: Labs and Diagnostic Test to be ordered (if applicable) Pulmonary Function Test (PFT) to evaluate lung function and help confirm the diagnosis of asthma. Chest X-ray to rule out any other respiratory conditions. Allergy testing to identify any potential triggers for the patient's asthma symptoms. Pharmacological treatment: Albuterol inhaler (short-acting beta-agonist) as a rescue inhaler for quick relief of asthma symptoms as needed. Fluticasone/salmeterol inhaler (combination of an inhaled corticosteroid and a long-acting beta-agonist) as a maintenance inhaler to prevent asthma symptoms and reduce airway inflammation. Non-Pharmacologic treatment:

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Avoiding triggers that can exacerbate asthma symptoms, such as smoke, pollution, and allergens. Learning and practicing proper inhaler technique to ensure effective medication delivery. Regular exercise to improve overall respiratory health. Education: The importance of adhering to the prescribed medication regimen, including both rescue and maintenance inhalers. Understanding and recognizing the signs and symptoms of an asthma attack and knowing how to use a rescue inhaler. Developing an asthma action plan with the patient to help manage symptoms and prevent asthma attacks. Avoiding exposure to common triggers for asthma symptoms. Follow-ups/Referrals: Follow-up appointment with primary care provider in 2-4 weeks to assess response to treatment and adjust medication regimen as needed. Referral to an asthma specialist if symptoms are not well-controlled with initial treatment or if there are other complicating factors such as frequent exacerbations or comorbidities. References: American Lung Association. (2021). Asthma. https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma National Heart, Lung, and Blood Institute. (2020). Asthma. https://www.nhlbi.nih.gov/health-topics/asthma

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