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    Asthma Resp Acr Did Soap Note

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    This 22-year-old female presents with a 3 month history of cough, dyspnea, and wheezing that has progressively worsened, especially with smoking or exercise. On examination, she has wheezing and rhonchi throughout her lungs bilaterally. The working diagnosis is asthma, and she is prescribed a SABA inhaler PRN and combination LABA/ICS inhaler daily, along with lifestyle modifications including smoking cessation.

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    Asthma Resp Acr Did Soap Note

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    veronica
    4K views1 page
    This 22-year-old female presents with a 3 month history of cough, dyspnea, and wheezing that has progressively worsened, especially with smoking or exercise. On examination, she has wheezing and rhonchi throughout her lungs bilaterally. The working diagnosis is asthma, and she is prescribed a SABA inhaler PRN and combination LABA/ICS inhaler daily, along with lifestyle modifications including smoking cessation.

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    This 22-year-old female presents with a 3 month history of cough, dyspnea, and wheezing that has progressively worsened, especially with smoking or exercise. On examination, she has wheezing and rhonchi throughout her lungs bilaterally. The working diagnosis is asthma, and she is prescribed a SABA inhaler PRN and combination LABA/ICS inhaler daily, along with lifestyle modifications including smoking cessation.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    4K views1 page

    Asthma Resp Acr Did Soap Note

    Uploaded by

    veronica
    This 22-year-old female presents with a 3 month history of cough, dyspnea, and wheezing that has progressively worsened, especially with smoking or exercise. On examination, she has wheezing and rhonchi throughout her lungs bilaterally. The working diagnosis is asthma, and she is prescribed a SABA inhaler PRN and combination LABA/ICS inhaler daily, along with lifestyle modifications including smoking cessation.

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    Clinical Performance Evaluation Asthma ACR-DID

    DO 2017 - 1/15/2015

    Student Name:
    Evaluator:

    Date:

    Complete a written note in the SOAP note form in the space provided. Write in the box only.

    S CC: "I've been coughing"


    HPI: 22-year-old girl presents to the clinic with complaints of cough and dyspnea for the past 3 months. Onset seemed
    to begin when she started smoking and has never happened before. She admits to a steady progession of her symptoms
    that are now present with nocturnal cough and chest tightness up to 3 times per week. Cough is described as dry and
    wheezing. Dypsnea worsens with moderate activity (such as fast walking) and when she or her friends smoke
    cigarettes. Symptoms improve when she rests and gets fresh air. Denies any recent sick contacts or travel. There is no
    associated pain with the episodes of coughing. She denies any mucus production, fevers, rhinorrhea, epistaxis, or
    hemoptoysis.
    Allergies: none
    Meds: OCP PO qd for birth control.
    PMHx: None
    PSHx: None
    FmHx: mother and father healthy; brother has asthma
    SocHx: EtOH-never; Drugs-never; Tobacco-1 pack/wk for 3 months. Diet- balanced and "healthy"; Does not exercise
    frequently. Lives with roommate, attends local community college. Sexually active with boyfriend, uses OCP.
    ROS:
    GEN: No fever, No recent wt loss
    CV: No palpitations, no chest pain.
    EXT: No arthralgias, no stiffness
    PSYCH: Denies anxiety or depression
    O
    T: 98.7 F P 70 RR: 16 BP: 120/80 O2: 98% on room air BMI: 21 kg/m3
    GEN: WDWN, NAD. Appears stated age.
    Eyes: No conjunctival injection. Sclera white and clear b/l.
    Nose: septum midline, nasal mucosa moist and pink. Maxillary and frontal sinuses NT to palpation.
    Throat: oral mucosa without abnormalities
    Neck: supple with no masses. No LAD.
    CV: RRR. S1 and S2 present. Dorsalis pedis and radial pulses equal and present b/l.
    RESP: Auscultation reveals fine end-expiratory wheezing with scattered rhonchi throughout lungs b/l.
    Percussion is resonant in all lobes b/l. Chest wall expansion is adequate. Vocal fremitis and egophony within
    normal limits B/L.
    EXT: No cyanosis or clubbing, no edema in LEs B/L
    OMM: TART changes noted b/l T2-T7.

    Working Dx) Asthma


    Ddx) Bronchitis, Hypersensitivity pneumonitis,
    emphysema, PNA

    Test: PFTs, Spirometry, Metacholine challenge test


    Prescribe SABAinhaler PRN and LABA and ICS:
    Salmeterol and Beclomethasone inhaler qd

    Lifestyle: Nicotine Dependency; sedentary


    lifestyle

    Follow-Up: 1 week or if symptoms worsen/persist


    with medications

    OMM: SD at T2-T57

    Pt Ed: When to use LABA and ICS, avoidance of


    triggers, smoking cessation

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