SOAP NOTE

Reason for Seeking Health Care: " The patient complains of persistent cough, severe wheezing, and difficult breathing, which began earlier today."

HPI: ________P. K is a ten-year-old male of African American origin who presents with complaints of severe wheezing, a persistent cough for three days, and difficulty breathing, which began 12 hours ago. Despite using a rescue inhaler, the patient's symptoms have worsened since the onset of breathing concerns. The patient reports having a cold before the current exacerbation and dust allergy, where he engaged in a cleaning activity in school early this week. ______________________________________________________________________________

Allergies (Drug/Food/Latex/Environmental/Herbal): dust and cold ____

Current perception of Health: Excellent Good ✅ Fair Poor

Past Medical History

• Major/Chronic Illnesses. K was diagnosed with asthma at five years old
• Trauma/Injury _____________no history of past injuries
• Hospitalizations __________he has had three hospitalization episodes with complaints of pneumonia, which were well managed.

Past Surgical History: history of past surgical procedures for the patient

Medications: the patient has been using an albuterol inhaler (90 mcg) for wheezing and fluticasone propionate 50 mcg B.D.

Family History: both the mother and the father are alive, and they live with him. The mother has recently been diagnosed with high blood pressure. The paternal grandfather passed a year ago due to esophageal cancer with a long history of smoking, and he was a known asthmatic patient.

Social history:

Lives: Single-family House/Condo/ with stairs

Marital Status: single

Status: student

Current/Previous occupation type: not applicable

Exposure to: _Smoke__nil ETOH: nil

Recreational Drug Use: nil

Sexual orientation: male

Sexual Activity: no reports

Contraception Use: not applicable

Family Composition: Family/Mother/Father/Alone: P. K lives with his parents and three years old younger brother

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, etc. The mother reports that P.K. was taken for an asthma review one year ago. _

Exposures: No history of exposure

Immunization H.X.: his immunization history is up to date

Review of Systems:

General: The patient seems restless and tired due to breathing difficulty.

HEENT: There have been no head issues like injuries, changes in vision or discharge, ear discharge or pain reported, signs of nasal congestion, or nil sore throat.

Neck: There are no changes in neck range of motion, no swollen lymph nodes, and no pain reported

Lungs: There is reduced air entry and severe wheezing

Cardiovascular: Positive signs of tachycardia

Breast: no complaints

G.I.: No vomiting, no nausea, no diarrhea complaints, and no abdominal pains

Male/female genital: no complaints

GU: No painful urination or abnormal penile discharge noted.

Neuro: The patient appears anxious yet alert and well-oriented to time, place, and person.

Musculoskeletal: No changes in the range of motion; he reports feeling weak; no reports of injuries

Activity & Exercise: Due to asthma flares, he has limited engagement in exercise routines.

Psychosocial: The patient is anxious due to breathing concerns. His mother and the family provide necessary emotional support.

Derm: No itches or rashes reported

Nutrition: The patient gets adequate food; he looks healthy and energetic.

Sleep/Rest: A disturbed sleep pattern is due to severe wheezing and coughing.

LMP: not applicable

STI Hx: not applicable.

Physical Exam

BP_____110/70mm Hg___

TPR__37.2 degrees Celsius ___

HR: _112bts per minute ____

RR: __26 breaths per minute __

Ht. __141 cm___

Wt. _____90 lbs._

BMI (percentile) _87% weight for ag percentile

98% height for the age percentile

Healthy weight for height: 72.7-99.3lbs (Calculator.net, 2019)

Ponderal index-11.5kg/m³ (Calculator.net, 2019) ____

General: The patient appears restless and anxious following his difficulty in breathing. He is leaning forward and sitting upright to enhance breathing, a common position among patients with repository issues.

HEENT:

The head is atraumatic and normocephalic

The eyes are equal and round and react to light and accommodation. There is no eye discharge or conjunctival redness.

The ears have no discharge, pain, or inflammation, and the tympanic membrane is intact.

There is nasal flaring, no running nose, and the mucous membranes are normal.

There is no sore throat, exudates, erythema, or lesions.

Neck: No swollen nodes, no jugular enlargement, and the trachea is midline.

Pulmonary: The chest wall is symmetrically moving with some effort noted; there is no tenderness on the chest wall, no signs of consolidation, and no percussion resonance. On auscultation, there are bilateral diffuse wheezes and more pronounced expiration. Reduced breath sounds in the lower lobes suggest an airway concern during an acute asthma exacerbation.

Cardiovascular: No murmurs, S1 and S2, rubs, or gallops were heard. The heart rate increased.

Breast: No discharge or pain

G.I.: No tenderness, no visible scars. Bowel sounds are present and normal in each quadrant.

Male/female genital: No abnormal discharge or tenderness was noted.

GU: No concerns with urination or bowel movement.

Neuro: The patient is alert and oriented to place, person, and time. He has no focal neurological deficits noted.

Musculoskeletal: signs of weakness, limited range of motion, no injuries.

Derma: Skin is warm, no rashes, dry skin, no unusual markings

Psychosocial: There are signs of anxiety resulting from acute distress, but the patient is cooperative during the examination period.

Misc. not applicable

Persistent coughing

Wheezing

Difficulty in breathing, which started earlier today

Significant Data/Contributing Dx/Labs/Misc.

Plan:

Differential Diagnoses

1. Acute asthma exacerbation: This condition manifests with symptoms such as difficulty breathing, wheezing, and persistent cough. The patient's persistent use of an inhaler with no success supports this diagnosis.
2. Bronchospasmospasm is a condition that manifests with smooth muscle constriction in the small airways. Due to their unique anatomy, the pediatric population is often more prone to the condition. The condition presents wheezing as a significant characteristic among the patients, which can be identified on physical exams (Edwards et al., 2023). The child with the problem complains of shortness of breath, chest tightness, cough, and, at times, "noisy breathing" (Edwards et al., 2023).

1. 3. pneumonia: Considering the treatment-refractory treatment for a patient with asthma necessitates considering an alternative diagnosis. Fever, tachypnea, acute respiratory symptoms, and radiologic evidence of infiltration of the parenchyma must be regarded as pneumonia diagnosis (Johnson et al., 2019).

1. 4. Chronic sinusitis: sinusitis is a significant condition with manifestations similar to asthma, including shortness of breath due to turbinate edema and cough caused by the post-nasal drip. Also, air pollution and infection exposure can trigger sinusitis similar to asthma. The condition affects about 15% of the U.S. population with symptoms such as sinus discharge, nasal congestion, reduced ability to smell, and facial pressure (Johnson et al., 2019).

Principal Diagnoses

1. 1. Acute asthma exacerbation: The primary diagnosis leading to the admission of the patient remains an acute asthma exacerbation, which can be attributed to the acute presentation with breathlessness, persistent cough, and wheezing while having a past diagnosis of asthma.

1. 2. allergic rhinitis: This is an allergic reaction that results in symptoms such as a sore throat, nasal congestion, and sneezing among patients. It happens when someone gets irritated by an allergen such as pollen, cold, or dust, resulting in sneezing and other symptoms.

Plan

Diagnosis: Acute asthma exacerbation

Diagnostic Testing: Peak expiratory flow rate is a simple measure of the maximal flow rate achievable from a forceful expiration following a full inspiration. It is often used in the daily or needed ambulatory asthma evaluation, which helps measure how well the patient can breathe (DeVrieze et al., 2023).

Pharmacological treatment: administer nebulized albuterol and ipratropium (Morris, 2019). In managing an asthmatic attack, levalbuterol and albuterol are the most commonly used inhaled quick medicines (Morris, 2019). For the patient, ipratropium will also help enhance airway openings, which can be administered through a nebulizer or an inhaler. In case the symptoms persist, it is essential to administer a corticosteroid, which helps to reduce inflammation. The patient must also be put on oxygen therapy to aid in breathing and get the necessary extra oxygen, which will be done via a breathing mask.

Patient education: The patient needs to be educated on allergic trigger avoidance, including known allergies such as cold and dust. Also, the patient needs to be educated on the necessary asthma action plan while ensuring he is aware of the necessary emergency response when there is an imminent feeling of an acute complication, which includes symptoms such as progressive coughing. Consider training the patient and the mother on the right inhaler use technique, which could have worsened the condition since it started.

Referrals: Consider a pediatric neurologist to review the child if the treatment does not effectively manage his condition.

Follow-up: The patient needs to come for weekly follow-up care to determine his progress, followed by bi-weekly sessions to help evaluate his overall progress and coping strategies.

Anticipatory Guidance: The patient needs to be reminded of the necessary safety measures, such as avoiding allergen exposure, such as dust and cold experiences. Also, the mother and son must be taught how to adhere to the asthma action plan. The mother needs to be enlightened on what the various zones mean and the clinical manifestations that help mark each zone. This can either be done well, in a yellow or caution zone. Teaching them the essential warning signs of asthmatic attack is also important to promote overall adherence to emergency care and prevention of such exacerbations in the future, which could be life-threatening. If the patient exercises in a cold or dusty place, they need to do so in a mask, which helps reduce the direct access of such triggers to their pulmonary system. It is also essential for the mother to offer him a nutritious diet that helps prevent weight gain, which is known to worsen asthma concerns.

Diagnosis: allergic rhinitis

Diagnostic Testing: The nasal inspiratory flow test helps measure the airflow when the patient breathes in via the nose. Allergic skin testing is also commonly used to determine if an allergy to a partial substance is involved. On the other hand, a basophil activation test is helpful to diagnose the allergic phenotypes of rhinitis among patients, where detection of IgE-dependent allergen-specific responses among allergic patients is demonstrated through a positive response from the method (Testera-Montes et al., 2021).

Pharmacological Treatment: Administer cetirizine or loratadine, which are antihistamines that help manage nasal congestion and other symptoms, such as nasal drainage.

The administration of nasal corticosteroids, such as fluticasone, helps promote breathing and minimize nasal inflammation (Morris, 2019). Thirdly, the patient needs to be managed with montelukast. This leukotriene receptor antagonist helps manage asthma and allergic rhinitis symptoms, such as nasal congestion, among patients.

Education: the patients need to be enlightened on the impact of allergen exposure on their overall well-being, including their past asthma diagnosis, which could result in fatal outcomes if not well managed. Teaching them about environmental triggers such as cold and dust, among others, helps promote disease prevention.

Referrals: In the case of the child, it is essential to consider a referral to an allergist. This care provider specializes in allergy skin testing, where they tell exactly what has caused the symptoms.

Follow-up: Organize with a specialist or a long-term care provider from the primary care center.

Anticipatory Guidance: It is essential to offer Guidance on symptom recognition and management by the mother. This enlightens the mother and the child to seek medical attention whenever warning signs are present and identify signs such as shortness of breath. It is also essential to avoid various allergic triggers that exacerbate cases. The mother and the patient should also be taught to adhere to the treatment regimen and go for follow-up care as needed.

Signature (with appropriate credentials):

Cite current evidence-based guideline(s) used to guide care (Mandatory)______the literature and support guidelines for asthma management are based on the following organizations:

1. National Asthma Education and Prevention Program (NAEPP) (Morris, 2019)
2. Global Initiative for Asthma (GINA) (Morris, 2019) _________

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)_________P. K_____________________ Age ______10 years_____

Date: __________25^th April 2024_____

RX albuterol for inhaler use

Prednisolone 5 mg O.D. for 14 days

SIG:

• Dispense:
• albuterol- 1 vials of 3 ml
• Prednisolone-14 tablets
• fluticasone propionate 50mcg BD _______ Refill: every follow clinic ______

✔️

No Substitution

Signature: ____________________________________________________________