SOAP Note #3 Main Diagnosis: Asthma

Posted: March 20th, 2024

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:

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:

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

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.

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:

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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