SOAP NOTE

S: SUBJECTIVE DATA

CC:

“I have been coughing and feeling short of breath for the past three days. My chest feels tight, and I have a mild fever.”

HPI:

AB is a 35-year-old Caucasian female who presents with complaints of a persistent cough and shortness of breath that started three days ago. The cough is productive, bringing up clear to white sputum. She describes her chest as tight, particularly when coughing or taking deep breaths. She has noticed wheezing and mild fever with a maximum recorded temperature of 37.9°C. She denies any recent travel or known sick contacts. Her symptoms are aggravated by physical exertion and are somewhat relieved by her rescue inhaler, but the relief is temporary. She denies any sore throat, nasal congestion, or ear pain. Her last asthma exacerbation was about six months ago.

PMH:

The patient has no history of hospital admissions for asthma. Asthma was diagnosed at age 12. Seasonal allergies.

PSH

The patient had an appendectomy at age 20.

FH

Father: 65 years old, hypertension.

Mother: 62 years old, asthma.

Brother: 38 years old, no significant medical history.

SH

Married with two children, works as a school teacher.

Non-smoker drinks alcohol occasionally (1–2 drinks per month).

Exercises moderately engage in light jogging and yoga.

Follows a balanced diet, mostly home-cooked meals, and avoids known allergens.

R

Constitutional

Positive: Mild fever.

Negative: Chills, weight loss, fatigue, weakness..

Head

Negative: Headache, dizziness, syncope

Eyes

Negative: Vision changes, eye pain, discharge, redness.

Ears, Nose, Mouth, and Throat

Positive: Throat mildly erythematous.

Negative: Ear pain, hearing loss, nasal congestion or discharge, oral lesions.

Neck

Negative: Pain, stiffness, swelling, masses.

Cardiovascular

Negative: Chest pain, palpitations, peripheral edema.

Respiratory

Positive: Persistent cough, shortness of breath, wheezing, chest tightness.

Negative: Hemoptysis, pleuritic chest pain.

Gastrointestinal

Negative: Abdominal pain, nausea, vomiting, diarrhea, constipation, hematemesis, melena.

Genitourinary

Negative: Dysuria, hematuria, urinary frequency or urgency, genital lesions.

Musculoskeletal

Negative: Muscle pain, joint pain, swelling, stiffness, trauma.

Integumentary

Negative: Rash, itching, bruising, changes in skin color or texture, lesions.

Neurological

Negative: Numbness, tingling, weakness, seizures, balance problems.

Psychiatric

Negative: Anxiety, depression, insomnia, mood swings, memory loss.

Endocrine

Negative: Excessive thirst or urination, heat or cold intolerance, recent changes in weight.

Hematologic/lymphatic

Negative: Unusual bleeding or bruising, swollen glands, petechiae.

Allergic/immunologic

Positive: Seasonal allergies.

Negative: Food allergies, drug allergies, frequent infections.

O: OBJECTIVE DATA

VITALS:

HR: 90 bpm

RR: 20 bpm

Ht: 5’6”

Temp 37.8°C

BP: 118/76 mmHg

SpO2: 94% on room air

Wt: 140 lbs

BMI: 22.6

AGE-SPECIFIC

FINDINGS:

The patient is in the early adulthood stage (ages 18 to 40 years), where Erikson's concept of "Intimacy vs. Isolation" applies. This stage focuses on forming intimate relationships and meaningful connections, which she achieves through her family life and professional role as a teacher (World Health Organization, 2024).

Physical Exam

General Appearance

The patient is well-nourished, but in mild distress due to coughing and shortness of breath.

Head

Atraumatic, normocephalic.

Eyes

PERRLA, no conjunctival injection or icterus.

ENT, Mouth

Throat mildly erythematous, no exudate. The Nasal mucosa is slightly inflamed, but there is no significant discharge. Tympanic membranes normal.

Neck

Supple, no lymphadenopathy or thyromegaly.

Cardiovascular

Regular rate and rhythm, no murmurs, rubs, or gallops.

Respiratory

Positive: Persistent cough, shortness of breath, wheezing, chest tightness.

Negative: Hemoptysis, pleuritic chest pain.

GI

Negative: Abdominal pain, nausea, vomiting, diarrhea, constipation, hematemesis, melena.

GU

No costovertebral angle tenderness.

Musculoskeletal

Full ROM, no tenderness or deformity.

Skin

Warm, dry, no rashes or lesions.

Neurological

Negative: Numbness, tingling, weakness, seizures, balance problems.

Psychiatric

Negative: Anxiety, depression, insomnia, mood swings, memory loss.

Endocrine

Negative: Excessive thirst or urination, heat or cold intolerance, recent changes in weight, changes in hair or skin texture.

Hematologic/lymphatic

Negative: Unusual bleeding or bruising, swollen glands, petechiae, anemia symptoms..

Immunologic

Positive: Seasonal allergies.

Negative: Food allergies, drug allergies, frequent infections, autoimmune symptoms..

Other

Negative: No recent travel or known sick contacts, no exposure to toxic substances.

A: ASSESSMENT AND DIAGNOSES

Prioritize

DIAGNOSIS

1

Asthma Exacerbation

ICD-10 J45.901

The patient's symptoms and history are consistent with an acute asthma exacerbation, characterized by increased cough, shortness of breath, chest tightness, and wheezing (Sinyor & Concepcion Perez, 2023).

2

Acute Upper Respiratory Infection

ICD-10 J06.9

The productive cough and mild fever suggest a concurrent upper respiratory infection that may contribute to the exacerbation (Pavón-Romero et al., 2021).

3

Mild Dehydration

ICD-10 E86.0

The patient’s mild fever and increased work of breathing could lead to fluid loss, contributing to mild dehydration (Papi et al., 2020).

P: PLAN

ACTIONS

1

Asthma Exacerbation

Diagnostic:

Peak flow measurement, pulse oximetry monitoring.

Therapeutic:

1. Albuterol 90 mcg/spray, 2 puffs every 4-6 hours as needed.
2. Continue maintenance of inhaler (Fluticasone/Salmeterol) as prescribed.
3. Prednisone 40 mg daily for 5 days.

Patient Education

1. Educate on proper inhaler technique.
2. Avoid known triggers.
3. Increase fluid intake.
4. Follow up in 1 week or sooner if symptoms worsen.

2

Acute Upper Respiratory Infection.

Diagnostic

1. None immediately indicated unless symptoms worsen.

Therapeutic

1. Increase hydration.
2. Use of a humidifier and saline nasal spray for comfort.

Patient Education:

1. Symptomatic treatment with over-the-counter medications such as acetaminophen for fever.
2. Rest and monitor for any signs of secondary bacterial infection.

3

Mild Dehydration

Diagnostic

1. Monitor input and output.

Therapeutic

1. Encourage oral rehydration solutions or increased water intake.

Patient Education

1. Signs of dehydration and the importance of adequate fluid intake.

.

PREVENTATIVE

Implementing strategies to guide health promotion and disease prevention for asthma patients entails critical steps. The nutritional approach entails encouraging diets containing anti-inflammatory foods that include fruits, vegetables, whole grains, and omega-3 fatty acids to reduce inflammation and boost respiratory health among PPS patients ( Hashmi et al., 2023). It is recommended that patients do not consume foods and drinks with processed sugars as they fuel inflammation. As a form of exercise, aerobic and strength training should be an important part of an individual’s lifestyle as it helps maintain bodily health and enhance lung capacity. However, regarding environmental factors, patients should avoid them, and in case of the exacerbation of asthma, it is recommended to choose the type of exercises that have a low impact on the body (Chakraborty & Basnet, 2020). Quit smoking, particularly for patients with asthma, because smoking can cause worsening of asthma and more frequent severe attacks. Refusal of products that trigger allergic reactions and skin irritants and strict usage of asthma controller medicines reduce the chances of an asthma attack (Binns et al., 2022). Lecturing the learners on how to use the inhaler properly, how to follow the asthma management plan and signs of worsening asthma. Also, patients should follow recommended vaccinations, such as influenza and pneumococcal vaccines, in incidences of respiratory infections that may cause asthma.

FOLLOW UP

• Reevaluate asthma control and upper respiratory symptoms in 1 week.
• Return immediately if experiencing shortness of breath, chest pain, or severe coughing.

PRESCRIPTIONS

-

-

-

Albuterol HFA 90 mcg – 2 puffs every 4-6 hours as needed. #1 inhaler, 3 refills.

Prednisone 40 mg – Take 1 tablet daily for 5 days. #5, no refills.

Continue current maintenance of inhaler (Fluticasone/Salmetero)

CLINICAL REFLECTION

His clinical course can be described as a patient with the typical profile of asthma, which flared due to the precipitating factor – an upper respiratory tract infection. This plan provides for a short course of oral steroids and a higher usage of a rescue inhaler. The aims of patient education are symptomatic control, trigger recognition, and prevention of dehydration. If the patient does not resolve her symptoms and experience control of asthma, follow-up is mandatory.