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Soap Notes: Asthma

Student’s Name

Professor

Course

Date
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PATIENT INFORMATION

Name: George

Age: 59 years Old

Sex: Male

Source: Patient

Allergies: None

Current Medications

 Two puffs of PRN

 Albuterol inhaler

PMH: Asthma

Immunizations: Tetanus vaccine two years ago, 2021; Influenza vaccine last year,

2022 and Tetanus vaccine three years ago, 2020.

Surgical history: None

Family history: Father alive, 89 years old with hypertension, mother deceased,

causing stroke. Sister alive, 63 years with diabetes mellitus.

Social Hx: No alcohol use, No smoking. Has used alcoholic beverages during social

occasions. He married and lived with his wife and three children.

SUBJECTIVE:

Chief complaint: Wheezing and shortness of breath for the past three days.

Symptom analysis HPI: The patient is 58 years old with a history of asthma and has

been presenting serious shortness of breath and wheezing for the past three days. At

night, the symptoms are worse when involved in an activity. With the use of an

albuterol inhaler, the symptoms are relieved. The patient denies cases of vomiting,

diarrhea, cough, pulse, fever, nausea, chills, and chest pains.

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ROS:

CONSTITUTIONAL:

Vital signs: Pulse 90, BP: 135/85 mmHg, Temperature: 98.5 degrees f RR 22, Ht

180lb, PO2 -95% on room air, BMI 26.6. Report pain 0/10.

General Appearance: The patient is oriented at x3 and is alert. No acute distress was

recorded.

NEUROLOGIC: CNII-XII is grossly intact, alert, and oriented to time, place, and

person. The sensation is intact in the bilateral lower and upper extremities. Bilateral

UE/LE strength is 5/5.

HEENT: Head: Normocephalic, asymmetric, atraumatic and non-tender. There is no

tenderness in the maxillary sinuses. Eyes: No icterus, ni conjunctival injection. The

extraocular eye movements and the visual acuity are intact. There is no nystagmus

noted. Ears the Bilateral canals are patent with edema, erythema, or exudate. The

Bilateral tympanic membranes are intact. Moist nasal mucosa with no signs of

bleeding. There are no lesions on the oral mucosa, and it is wet.

Neck: Comfortable and can move with ease. There was no swelling in the neck area

or any form of discomfort. The thyroid gland was normal in size and palpable, and

shape and consistency were normal. The trachea is midline with no distended jugular

veins. The patient can move the neck in all directions without difficulty. There is no

revelation of any signs that relate to the patient’s asthma.

Cardiovascular: The S1S2 is normal and regular. There are no extra sounds with a

normal heartbeat. The refill of the capillary is less than 2 seconds. There is adequate

peripheral perfusion. No edema was observed. No wheezing or crackles in the lungs.

The lungs are clear to auscultation. There are no significant abnormalities in the

cardiovascular.
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Respiratory: Mild respiratory distress and increased work of breathing. There was

mild use of accessory muscles of respiration with a symmetrical chest expansion.

Decreased breathing is heard in some areas, with mild wheezing bilaterally in lung

fields. No crackles were heard. Oxygen saturation at its normal limits. Reduced forced

expiratory volume in one second (FEV1) and the forced vital capacity (FVC) as seen

on the spirometry. An increased ratio of FEV1/FVC was consistent with obstructive

lung disease (Cloutier et al., 2020).

Gastrointestinal: Non-distended abdomen, which is not tender and soft. Normal

bowel sounds in all quadrants. No masses or palpable organomegaly. No signs of

jaundice or ascites with no enlarged liver or spleen. No abdominal pain, vomiting,

nausea, or bloating.

Musculoskeletal: The patient can stand and walk easily, and no abnormalities are

observed. There is no sign of joint inflammation or deformity. The muscle strength is

intact, and all joints' range of motion is normal. No swelling or tenderness on soft

tissues or any joints. No major musculoskeletal issues were detected in the patient.

Integumentary: The skin is intact, with no rashes, discoloration, or lesions observed.

No evidence of peripheral cyanosis in the extremities or edema. Nail and hair texture

normal. No skin-related issues such as sensitivity, itchiness, or irritation. No

significant integumentary issues were detected.

Assessment: Differential diagnosis. Chronic obstructive pulmonary disease (COPD),

bronchitis, pneumonia, pulmonary embolism, or bronchitis. The asthmatic history of

the patient, spirometry findings, and characteristic symptoms give asthma the most

likely diagnosis.
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Primary diagnosis: Exacerbation of asthma. The patient needs treatment with

corticosteroids and bronchodilators to improve the functioning of the lungs and

alleviate symptoms.

Plan: The patient will be prescribed corticosteroids and bronchodilators to relieve

respiratory distress and improve lung functioning. Take controller medications such

as dust, smoke, and other triggers to stop worsening asthma symptoms.

CMP: The CMP is ordered to examine the blood glucose levels, liver and kidney

function, and electrolyte levels. This is to help regulate the adverse effects prescribed

medications can have on the body.

Non-Pharmacologic treatment: The patient was trained in diaphragmatic breathing

and pursed-lip to improve oxygen exchange and reduce shortness of breath. The

patient was advised to maintain a good diet and hydration to support lung function

and overall health (Bousso, Chenivesse, & Barnig, 2019).

Education: The patient was educated on proper asthma management, including

sticking to the medication regimen and proper inhaler techniques. Provision of action

plan when attacked by asthma.

Follow-ups: Regular follow-up visits with the patient's primary care provider will be

scheduled to track asthma symptoms and, if required, modify medication. If the

patient's symptoms are challenging to control or probable lung consequences from

asthma are a concern, a referral to a pulmonologist may be explored.

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References

Bousso, A., Chenivesse, C., & Barnig, C. (2019). Role of non-pharmacological

Interventions for asthma. Presse Medicale (Paris, France: 1983), 48(3 Pt 1),

282-292.

Cloutier, Michelle M., et al. "2020 focused updates to the asthma management

guidelines: a report from the National Asthma Education and Prevention

Program Coordinating Committee Expert Panel Working Group." Journal of

Allergy and Clinical Immunology 146.6 (2020): 1217-1270.